It is difficult to turn on the television or radio, or pick up a newspaper and not notice some mention of the opioid crisis in the United States. The volume on this hot button issue is also likely to increase the closer we get to the 2020 presidential election.
Before we delve into the very important discussion regarding the opiate epidemic, addiction and mental health, and treatment/prevention of opiate use disorders, let’s first talk about how we got here.
The Opioid Crisis in the United States
In the 1920’s through the 1980’s there was growing concern that medical providers were not paying enough attention to treatment of patients in pain. This so called “opiophobia” or fear of analgesics was deemed the culprit for under-treatment of pain. In response to this worry the American Pain Society decided to include pain as an additional vital sign. This meant that along with standard vital signs like pulse, blood pressure, weight/height and temperature, pain would become known as the “fifth vital sign.” While the push to adequately treat pain was well-intended, it led to disastrous consequences.
The Decade Against Pain
2000-2010 is known as the “decade against pain.” This stems from a multitude of systemic interventions that although well-meaning, ultimately put patients at significant risk for becoming addicted to and/or dying from opioid overdose due to overprescribing.
During this time period the Food and Drug Administration (FDA) allowed drug companies to advertise pharmaceutical drugs on TV which allowed direct to consumer marketing. This piqued interest in analgesic medications and over time opiates became a commodity that was highly sought after. To complicate matters further, there was a case of a physician in California who was convicted of battery for undertreating pain which drastically changed the medical treatment landscape, forcing medical providers to lean toward prescribing analgesic medications. To make matters worse, in 2005 Medicare linked reimbursement to pain management. This created an incentive to prescribe patients with opioids whether they were clearly indicated for treatment or not. This practice directly stems from the move toward pain management being an indicator of quality of care.
While it is a reasonable expectation that patients receive adequate pain management in the context of grave injury, surgery, serious medical illness, etc. Responsible prescribing of these medications is of the utmost importance given the potential negative effects opioids can have on a person’s life. The reverberations of overprescribing are still felt today.
Rise in Death Toll
In 1990 there was a sharp rise in opioid related deaths which was followed by an increase in heroin overdose deaths in 2010. This is particularly important because those who are addicted to opioid analgesics are 40 times more likely to use heroin in their lifetime. Heroin overdose deaths were in part due to the decrease in price of the drug which became seven times cheaper than it was in the 1980’s.
Between 1999 and 2017 there was a six-fold increase in opiate overdose fatalities. This is an increase from 8,048 to 47,600 people across the United States. In 2013 synthetic opioids contributed to 130 overdose deaths per day, 80% of these deaths were attributed to fentanyl.
Fentanyl is particularly dangerous because it is 50-100 times more potent than morphine. Ease of manufacturing and transport contributes to easier access. Fentanyl is often mixed with other substances including heroin and cocaine in unknown quantities. This means that people often don’t know what they are taking which increases risk of overdose and death.
Dual Diagnosis: Substance Use & Mental Health
People who struggle with addiction are also more likely to have a mental health disorder and vice versa. Let’s take chronic pain for example. Chronic pain is often comorbid with major depressive disorder. The converse is also true. Those with major depressive disorder are also more likely to have comorbid chronic pain. What this means is that depression and addiction is often a two-way street. Depression is associated with increased risk of opioid misuse and overdose. And those with a history of addiction are more likely to experience depression which may be increased during durations of opioid use.
Why is it important to recognize?
Because individuals with a history of depression are more likely to receive higher daily doses and a larger supply of opioid medications. More than half of people who use psychotherapeutic drugs are consumers of prescription analgesics for non-medical reasons. This is particularly concerning because 16% of adults in the United Sates have a mental health disorder… but they account for 50% of all opioid usage. Data shows that 19% of adults with a mental health disorder use opioids as opposed to 5% without a mental health disorder use opioids.
Responding to the Opioid Epidemic
We know that the opioid epidemic has claimed thousands of lives. The next question is… what can be done to address the problem? Responsible prescribing is a great place to start because no one is immune to addiction. Opioid prescribing practices is a key place to intervene given that 36% of overdose deaths involved a prescription opioid medication. It is also important to provide consumers of these medications with a reversible agent in the case of overdose. Access to opiate antagonists is critical and can save lives in the event of an overdose. Access to addiction treatment is perhaps one of the services most lacking in the United States. Only 12% of Americans who need addiction treatment have access to it.
Responsible Prescribing of Opioids
- Opioids should not be treated as a first-line therapy for pain, other options should also be carefully considered
- Clinicians should establish goals for pain and function with patients as complete elimination of pain may not be possible
- Clinicians should discuss the risks and benefits of opioids with patients particularly risk of addiction, overdose, and death
- Use lowest effective dose for adequate pain management
- Prescribe short durations for acute pain
- Evaluate benefits and harms frequently
- Use strategies to mitigate risk i.e. including offering overdose reversal therapies
- Avoid concurrent opioid and benzodiazepine prescribing given increased risk of respiratory suppression and death
Prevention of Opioid Use Disorder
- Consider other options i.e. Physical therapy, rest, ice, and non-opioid medications
- Try to reduce medical exposure – Research has shown that patients prescribed opioid medications for pain can become addicted even when drugs are taken as prescribed
- Responsible prescribing- over-prescription of opioids for acute pain is the main source of drug diversion
- Unused opioids- should be returned to pharmacy to minimize risk for potential misuse or abuse
- Early detection of opioid misuse/abuse is critical, if you suspect someone is struggling with addiction encourage them to seek help
- Prescription Drug Monitoring Programs (PDMPs) – a system currently used by 49 out of 50 states to track prescribing and dispensing of controlled substances to patients. In California it is called the “CURES” system. This is an attempt to curb “doctor shopping” where people go to doctors in different towns or states in order to get opioid prescriptions. It is illegal for providers to prescribe opiate medications without first checking this database
Reversing Opioid Overdose
Rescue kits save lives, and education and distribution are key. Opioid overdose kits are necessary for people with a history of addiction, overdose, or who are prescribed opioids or benzodiazepine medications. Opioid reversal agents are very effective, but they do wear off which means that
individuals who recently overdosed may not be completely out of danger. Although these reversal kits provide a short-term solution, there needs to be a long-term plan in place to help those at risk receive the addiction treatment they need.
Treating Opioid Use Disorders
One of the many excuses we hear regarding lack of available substance use treatment programs is the cost. However, it is important to note that for each dollar that goes toward substance use treatment, society saves on average 8-10 dollars. This makes sense if you think about the cost of calling 911, dispatching an ambulance, stabilizing a person during the ambulance ride, and the cost of emergency medical intervention and a multi-day hospitalization.
Unfortunately, there is no one size fits all approach to addiction treatment. However, the more
multi-modal the treatment strategy, the longer it lasts, and the more likely it is to be successful. Multi-modal or multi-faceted approaches to addiction treatment include psychosocial, pharmacotherapy, and harm reduction.
The harm reduction approach is geared toward those who do not do well with treatment or cannot be treated given the complexity of their circumstances i.e. Homelessness, lack of health insurance, serious mental illness, etc. This is where interventions like needle exchange programs and overdose rescue kits come into play. The idea is to reduce the potential harms that can happen when a person is struggling with addiction i.e. Minimizing transmission of blood borne pathogens, infections, and overdose deaths.
The reality is there are far more people affected by addiction than there are specialty physicians to treat them. What we need is to come together, collaborate, and work toward providing treatment to those who are suffering. It is important to remember that no one is immune to developing an addiction, and by getting involved and making a difference, the next life that could be saved is yours or someone you love.