The 21st Century Epidemic
Every day in America more than 116 men and women die from opioid overdoses. As recently as 2015, the National Survey on Drug Use and Health reported that nearly 40% of American adults used opioids to relieve pain. More than one-third of these adults were misusing the drugs. Sixty percent were taking these opioids without a prescription and more than 40% were given opioids from friends or family. This survey found that 1.9 million individuals had a documented substance abuse disorder. Substance Use Disorder (SUD) affects all ages, sexes, ethnic & socioeconomic backgrounds; although some areas of the country have a higher incidence of SUD and opioid-related deaths.
Despite a decrease in opioid prescriptions since 2010, deaths continue to rise as heroin has become a more frequent first agent for those with an SUD. Opioid-related deaths are rising, most likely due to illegally manufactured fentanyl and heroin. Heroin laced with potent illegal fentanyl or carfentanil (50-5000 times more potent than heroin) is a major cause of the increase in overdoses and deaths .
Opioids in the U.S.: Good Intentions Gone Bad
The historical perspective of opioids in the U.S. helps to understand opioid misuse. Going as far back as the nineteenth century, there was no regulation of cocaine and opioids in America until the Harrison Narcotics Tax Act of 1914. During that time, addiction was not recognized as a disease, and practitioners were incarcerated and/or lost their licenses if they prescribed opioids. The fear of addiction and incarceration led to the inadequate treatment of pain.
By the 1990s U.S. medicine became aware of the under-treatment of chronic pain and the need to change practice, turning to opioid analgesia for chronic, as well as acute pain. Pain was recognized as “the fifth vital sign”, and in 2000, the Joint Commission adopted this as an important pain management standard. The pharmaceutical industry began producing extended-release formulations, transdermal patches and other easily deliverable forms of administration while aggressively marketing to prescribers. Chronic pain became a big business, and many believe this was a key factor in the rise in opioid analgesia use and misuse.
One study indicates three major forces that influenced the increasing use of opioids and ultimately the crisis. The initial driving force, underlying the prescribing of opioids for pain, is that practitioners have a moral duty to alleviate suffering and manage pain. The second force is the role of pharma in marketing the use of opioids for chronic, non-cancer pain. In 2007, Purdue Pharma, the manufacturer of Oxycontin, was federally fined for misbranding. The third major driving force was a clinical practice change to aggressively manage all pain in an effort to improve the quality of care. Opioids became the answer to managing all types of pain, including non-cancer pain, sports injuries, and post-operative pain. The Institute of Medicine’s (IOM) call for improving patients’ health care experiences contributed to an increase in pain prescriptions, equating pain control with quality of care. Evidence of another good intention gone bad. (IOM, 2001) Prescribers were driven by patient satisfaction and reimbursement for hospital care became tied to patients’ perceptions of pain control.
Response to the Crisis
The frightening numbers of opioid-related SUD and opioid-related deaths are driving practice changes. As the opioid crisis escalated, the Joint Commission revised its recommendations for aggressive pain assessment and management in 2009. The Department of Health and Human Services is funding treatment programs, prescription-drug monitoring programs, increasing naloxone accessibility to prevent opioid-induced deaths, and developing guidelines for opioid prescribers. Federal recommendations include considering non-opioid pain management strategies to manage pain. The Center for Medicare and Medicaid Services (CMS) is transitioning to new questions in the Hospital Consumer Assessment of Health Care Providers and Systems (HCAPHS) survey, which ask if patients who experienced pain were asked about their pain and how to best manage it. Bills are currently in the House and Senate to encourage appropriate use of opioids for malignant or terminal pain and reimbursement for evidence-based alternative pain management interventions, such as acupuncture, for chronic pain. Prescription pain medications for acute pain, especially post-operative pain, are limited in amount dispensed and the number of days needed.
In addition to the tragic opioid-related deaths, the financial impact that the opioid crisis has had on health care is also driving practice change. Health care systems have recognized that administration of opioids to patients during their hospital stays resulted in increased cost, prolonged hospital stay and an increase in readmission rates. A retrospective study of surgical patient outcomes demonstrated that patients who had opioid-related adverse drug events, such as ileus, had a 3.4 increase length of stay, costing an additional $5,000 dollars/patient.
Opioid Use In 2018: Balancing Efficacy and Safety
The opioid crisis is one of the most serious public health concerns our nation has ever had to face. We must advocate for appropriate use of opioids for those with cancer-related or terminal pain so that we do not lose hard-earned gains in improving the quality of cancer and palliative care pain management for those with life-limiting illnesses.
We must adhere to safe prescribing of opioids by:
- Utilizing risk mitigation strategies, including drug monitoring systems
- Establishing universal precautions in prescribing
- Educating patients and families in safe usage, storage and disposal of opioids
Equally important is to advocate for those with SUD to get the help they need so that the number of opioid-related deaths decrease. Access to mental health and addictive disease services and reimbursement for the cost of these services must be available in all 50 states for all suffering with SUD. We must support legislation that supports safe and effective pain management. It is our responsibility to compassionately care for patients in pain while safeguarding our communities and our country.
It’s been about one year after a State of Emergency was declared and the Opioid Commission issued its recommendations. View our webinar to learn more about the state of the opioid epidemic in healthcare, including what progress has been made since the commission report release and declaration of federal State of Emergency. Aaron Williams, MA, Senior Director of Training and Technical Assistance for Substance Abuse for the National Council for Behavioral Health, moderates a discussion with clinical experts about the current state of healthcare as it pertains to moving the needle on the opioid epidemic.