By Dr. Linda Girgis
According to statistics compiled from the CDC, more than 165,000 people in the US died as a result of overdoses due to prescription medications from 1999 to 2014. The rate continues climbing with over 14,000 deaths in 2014 alone. While death is the most dangerous end-point, that is just the tip of the iceberg. It is estimated that approximately 2 million people in 2014 misused or abused prescription opioids. It is imperative to note that sales of these prescriptions rose at the same time indicating that prescribing of these medications fuels the opioid epidemic.
The public is now starting to recognize the American opioid crisis. This point was hammered home to many earlier this year when Rock N’ Roll Legend, Prince, was found dead in April due to an overdose of the opioid fentanyl.
Which opioid prescription medications are being abused?
- Opioids, which are medications used to treat pain. These include oxycodone, fentanyl, hydrocodone, codeine, methadone, Demerol and others.
- Central nervous system depressants, most commonly benzodiazepines.
- Stimulants, such as Adderall, Concerta, phentermine and others.
The current crisis focuses on opioid misuse, mainly because it is the most deadly but also it is a gateway to heroin addiction.
We are now seeing alarming increases of heroin use concomitant to the rising use of prescription opioids. These medications work by acting on the opioid receptors in nerve cells and reducing the sensation of pain. Over time, patients build tolerance to these medications and require higher doses to achieve the same effect. They also experience withdrawal symptoms if they stop taking the medication. Because these medications affect the brain regions that are responsible for reward, they often produce feelings of well-being and pleasure. Because of this euphoria, people often seek to take these medications in a way other than prescribed to achieve these feelings. Hence, it is easy to see how they can become addictive and are subject to diversion.
In response to the growing evidence of an opioid epidemic, in March 2016, the CDC issued new guidelines for prescribing these medications. According to CDC director Tom Frieden, MD, M.P.H., “More than 40 Americans die each day from prescription opioid overdoses, we must act now. Overprescribing opioids-largely for chronic pain-is a key driver of America’s drug-overdose epidemic. The guideline will give physicians and patients the information they need to make more informed decisions about treatment.”
Summary of CDC 2016 Guideline for prescribing opioids for chronic pain:
- Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Opioids should be considered only when the benefits outweigh the risks and, if used, should be combined with nonpharmacologic therapy and pharmacologic non-opioid therapy.
- Before starting opioid therapy, clinicians should establish treatment goals with all patients. It should be continued only if there is clinical improvement in pain and function and the benefits outweigh the risks.
- Before and during therapy, risks and realistic benefits should be discussed with the patient.
- Immediate rather than extended release formulations should be used when starting opioids.
- Opioids should be started at the lowest effective dose.
- When prescribing opioids for acute pain, 3 days’ worth of medication should be sufficient.
- Patients should be re-evaluated within 1 to 4 weeks of starting opioid medication or increasing the dose.
- Before starting and during opioid therapy, clinicians should access for opioid-related harm.
- Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program.
- Urine drug screening should be done before, and at least annually after, prescribing opioids.
- Prescribing opioids and benzodiazepines concomitantly should be avoided.
- For patients with opioid use disorder, evidence- based therapies should be offered.
The full guidelines can be found here.
In May 2016, after a 2-day joint committee meeting, the FDA announced that it recommends mandatory training for doctors who prescribe opioids. One committee member, Brian Bateman, MD, stated in an interview with Medscape, “We know prescription opioids carry considerable risks and that inappropriate prescribing has contributed to the current epidemic we are facing. It thus stands to reason that providers will benefit from training regarding their appropriate use”.
The White House shares the FDA’s recommendation. In February, POTUS Obama called on Congress to pass a $1.1 billion fund to help fight this epidemic. And just Friday he signed The Comprehensive Addiction and Recovery Act of 2016, which makes naloxone (an opioid antagonist) more readily available and helps states track and monitor prescription drug use.
“This legislation includes some modest steps to address the opioid epidemic,” Obama said in a statement. “Given the scope of this crisis, some action is better than none.”
The opioid bill expands prevention and education programs for teens and adults, but not for doctors. And, along with criticizing funding cuts to the bill, the president called for more education for doctors who prescribe painkillers.
However, doctors are not so readily agreeing with the mandatory training. The American Medical Association (AMA) came out expressing opposition to mandatory training. According to Dr. Patrice Harris, chair-elect of the AMA and chair of the AMA Task Force to reduce Opioid Abuse, “We support a voluntary approach to physician education and training, with the profession being responsible for articulating the standards and what is best for specific specialties and patient populations-rather than a one-size-fits-all response. Linking mandatory training on opioids to the DEA registration process raises legitimate questions of how to best ensure the competency of physicians and other prescribers, what are possible unintended consequences for patients and their physicians and what is the appropriate role of the federal government in this process”.
While the controversy simmers the Senate passed a bill on July 13, 2016 designed to fight the nation’s opioid epidemic. According to this bill, medical and law enforcement professionals will be provided more tools to help deal with those addicted to these drugs. Additionally, it would widen use of Naloxone, a medication used to treat overdoses. Despite the Senate support, lawmakers are still quibbling over funding of carrying out the law of this bill. The bill, in fact, represents a compromise between lawmakers but the question of funding has yet to be determined. According to Marvin Ventrell, the executive director of Addiction Treatment Providers, “To say that this bill without additional funding is meaningless would be a gross overstatement”.
The Opioid Epidemic: Where are we now?
After decades, the authorities in this country are starting to sit up and recognize the opioid epidemic and realize it is not going to get better without intervention. The use and abuse of opioids and other controlled substances continue to climb a scary ascent while the body count increases from over-doses related to these substances. While the focus now is on doctors’ prescribing habits, which is certainly a problem in the epidemic, the other culpable parties are being ignored. As a resident, pharmaceutical companies taught us that certain long acting opioids were not addictive. We now know they were wrong and they should step up and help devise some of the solution. Additionally, patients who “doctor-shop” were not being tracked before the state monitoring systems rolled out. Yet, health insurance companies received billing data knew exactly what medications they were paying for. They did nothing about it.
Insurance companies don’t always cover that help and perhaps they should be mandated to do so. However, diversion should be criminalized. A patient recently told me that 1 tablet of Percocet in my area sells for $20. But, the law enforcement field is overwhelmed and they rarely pursue these small time dealers. They need help to criminalize this because it is killing people. Where I practice, this drug diversion spurred an IV heroin epidemic in high school kids. I have seen kids as young as 14 addicted to it.
Yes, doctors need to prescribe these medications more appropriately. The CDC guidelines are a good start for those who have been prescribing them otherwise. Do we need mandatory training? Perhaps, but I think what we really need is more courage to stand up to our patients and tell them they have a problem and put down the prescription pads. As doctors we want to help. But, in this case, in our desire to relieve pain, we have harmed. We must do better. But, all the other parties need to step up to the plate and do their part, from pharmaceutical companies to the government to the nurses who see addicted patients, ALL of us. This epidemic is exploding and needs all hands on deck. How many more people will we bury before we team up and take action?
Linda Girgis MD, FAAFP is a family physician practicing in South River, New Jersey. She was voted one of the top 5 healthcare bloggers in 2016. Follow her on twitter @DrLindaMD.