Reversing the epidemic of drug overdoses

The evening news is filled with fatal car crashes and shootings. But drug overdoses kill nearly 40,000 people a year, accounting for more deaths than vehicular accidents or homicides.

Drug overdoses are on the rise in America, fueled largely by prescription meds. Reversing the course of this epidemic will require some dramatic changes.

The facts

Drug overdose rates climbed more than 100 percent between 1990 and 2012. But what most people don’t recognize is that nearly 60 percent of drug overdoses result from prescription medications. In fact, 3 in 4 drug overdose deaths involve an “opioid analgesic” pain killer such as oxycodone, hydrocodone or methadone.

Opioids can exact an enormous toll on human lives. Opioid use damages families and communities, and costs U.S. employers a fortune.

Non-medical use of prescription opioids costs the U.S. upward of $53 billion, according to the Clinical Journal of Pain. That’s $42 billion from lost workplace productivity, $8.2 billion in criminal justice costs, $2.2 billion from treatment and $944 million from medical complications.

These devastating effects aren’t isolated to any one community. They’re found in all communities: rural and urban, affluent and low income, minority and majority.

The history

For about 6,000 years, opioids have been used to treat pain and other medical conditions. The initial source of opioids was opium, derived from the Eurasian poppy. In the 1800s, morphine was isolated and synthesized, making it commercially available for the first time.

For several decades leading up to the 21st century, physicians debated the most appropriate use of these powerful drugs and their place in the therapeutic arsenal.

In the 1960s, America saw a sharp increase in the abuse of both prescription and illicit drugs. In response, the federal government began a crackdown on prescription drugs as Congress tightened restrictions to limit counterfeit prescriptions.

In parallel, there was a cultural shift within the field of medicine, resulting in a significant decrease in how frequently physicians used opioids to treat acute and chronic pain.

The pendulum swings

These developments drove down the quantity of opioids prescribed for pain, but some critics were concerned doctors and politicians had gone too far. Studies conducted in the late ‘80s and early ‘90s confirmed health care providers were, in some cases, under-treating pain.

So, the pendulum swung yet again. The field of medicine shifted its stance on pain management in the mid-1990s, viewing the broader use of opioids as a relatively safe treatment approach. There was a belief that a patient experiencing pain should be given as high of a dose of opioids as necessary for as long as necessary, regardless of the exact cause of discomfort.

Simultaneously, pain management experts – some funded by the manufacturers of these powerful medications – began assuring participants at continuing medical education meetings that dependence and addiction would not occur in the face of genuine pain.

We have since learned these assertions were wrong. But the damage was done.

And so we find ourselves yet again experiencing high use of opioids, prescribed in large quantities for the treatment of chronic pain.

As a nation, we have become the dominant prescribers and consumers of pain medications. While the U.S. makes up only 4.6 percent of the world’s population, we consume 80 percent of the world’s opioids and 99 percent of its hydrocodone, which is found in Vicodin.

The spillover beyond medicine is significant. According to the White House, nearly a third of people using illicit drugs for the first time began by using a prescription drug illegally.

Protecting America’s patients

The Institute of Medicine estimates that chronic pain affects roughly 100 million Americans, nearly a third of our country.

So there is a role for the use of opioids in treating acute pain after surgery or trauma, and in providing comfort care for chronic pain during terminal illness. But before prescribing them for conditions that are likely to be long-term, physicians need to assess whether a patient is at risk for drug dependence, addiction, abuse and overdose.

In addition, doctors must exercise caution when prescribing opioids, especially to people under the age of 18 who are at a much greater risk for dependence.

Further, physicians should take greater care in prescribing the minimal number of tablets necessary for the specific medical situation. If a patient has a surgical procedure or suffers an injury for which discomfort is anticipated to resolve in three days, then prescribing a three-day supply of opioids would be more prudent than 100 pills. Taken a step further, doctors should avoid prescribing these addicting medications for most patients with conditions that are likely to be chronic, including low-back pain, fibromyalgia and recurrent headaches.

Physicians and patients alike need to be aware of the “90-day cliff.” People who use opioids continuously for more than 90 days increase their likelihood of lifelong dependence.

And the longer a person takes these medications, the higher the dose needed to achieve the same level of pain relief, putting them at greater and greater risk of overdose. The risk of overdose and respiratory depression increases dramatically in patients who also have been prescribed muscle relaxants or benzodiazepines like Valium.

And once patients become opioid-dependent, weaning them off these medications can be extremely difficult. Unfortunately, many patients who become addicted to the drugs will engage in a variety of drug-seeking behaviors – many of which are criminal.

While integrated health care systems can use electronic medical records (EMR) for signs of doctor shopping and drug-seeking behavior, only broader statewide or regional databases can obtain the fuller picture. For example, prescription drug monitoring programs like the Controlled Substance Utilization Review and Evaluation System (CURES) in California has provide doctors with access to all of the different controlled substances a patient has been prescribed.

Improving care in the future

To stop the epidemic of prescription opioid abuse, overdose and death, physicians who prescribe these medications need to rethink their approach to these powerful drugs. Before ordering, each doctor should:

  • Weigh the risks and benefits of prescribing these powerful medications as part of a holistic treatment plan.
  • Ensure opioids are prescribed only for patients with conditions shown to respond well to them – and in the appropriate dosages.
  • Use the lowest dose possible to achieve the desired clinical effect and have a plan for tapering or discontinuing the medication when symptoms are controlled.
  • Monitor patients for signs of side effects and for abuse, misuse, dependency and diversion.
  • Ensure those patients who do start opioid therapy are aware of the risks inherent in long-term use and understand the plan to stop them.

Families and friends can encourage loved ones on these medications to obtain medical help in ending their dependence. Every patient with pain deserves compassionate and appropriate treatment. But physicians need to so in ways that protect lives, not jeopardize them.

Robert Pearl is a physician and CEO, The Permanente Medical Group. This article originally appeared on Forbes.com.

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  • guest

    This article doesn’t really tell any of us anything that we don’t already know.
    What we really need answers to are questions like the following:
    What do you say to hospital administrators who call you in to discuss low patient satisfaction scores that are a direct result of your refusal to prescribe opiates due to evidence of misuse, or abuse, of prescription pain medications?
    What does one do about the fact that many states actually have statutes that provide for discipline and/or prosecution of a physician who fails to adequately treat a patient’s pain.
    What do we as a profession do about the fact that pain has been dubbed “the fifth vital sign” but is the only vital sign for which there is absolutely no means of objective measurement?
    Who exactly pays for the extra time that is required to negotiate with patients over their pain meds when there are worrisome signs of abuse or dependence?
    And lastly, is anyone with any authority in the healthcare system actually out there advocating that pharmaceutical companies be required to bear any degree of responsibility for their role in producing and marketing ever-more addictive versions of these medications? Or can they do what they want and it’s just up to us individual practitioners to deal with the inevitable complications?

  • Mark S.B.

    Saying the U.S. consumes 99 percent of the worlds hydrocodone, which is found in Vicodin , is a wrong statement and just causes confusion beings though the U.S. is the only country that produces hydrocodone. No other country has this type medication available so how can the U.S. consume 99 percent of the worlds hydrocodone making it sound bad.

  • DoubtfulGuest

    If a patient responds yes to history of physical, emotional, or sexual trauma, what do you do with that information? What’s your thought process then?

  • DoubtfulGuest

    Your treatment strategy sounds great, only I hope the antidepressants are optional? I agree that psychotherapists who are experts in trauma can be tremendously helpful, and you’re doing patients a great service by making those referrals. Some are motivated to seek that help on our own. I was fortunate to have access to as much psychotherapy as I needed, through my university health system. I understand it’s harder to come by these days, which is a shame because so many people benefit from it.

    I just get nervous whenever I read that doctors “need to know” about a history of trauma or abuse, particularly if assumptions are made about addictions or personality disorders. I was not seeking pain medication of any kind. I was trying to get a diagnosis for what turned out to be a mitochondrial myopathy. My history of abuse was used as the sole basis for a neurologist’s conclusion that I was malingering. I didn’t deceive anyone. I didn’t even have any nonorganic signs on exam. This doctor told me that “people like you” can’t get attention any other way than to make up symptoms, can never have a healthy relationship or ever contribute anything to society.

    Years later, I’m getting the medical care I need, but I have not recovered from that experience. My disease is progressive (I’m still working), and it would have been better for me to start treatment earlier. So I ask doctors to be careful in these situations. I wouldn’t know about any predisposition toward opioid dependence. I’ve only ever used those medications for a couple of days after surgery. The side effects aren’t worth it to me. But patients with trauma history are not a special class of people who are more likely to do anything problematic. Thanks for your time.

    • Alan Wartenberg

      The problem in the treatment of any kind of drug abuse is that we, as a nation (as have other nations) focus on the DRUG, work to eliminate it, make it illegal, restrict it, prosecute people who use it etc etc etc. What we need to do is to focus on the predisposition – people who are in “psychic” rather than physical pain, where opioids are far more reinforcing than they are in others. Many, if not most people have the same reaction to them as you do – they appreciate the analgesia and hate the side effects.

      As an Addiction Medicine physician, it is what I see (or used to see, I am now mostly retired), and personality disorders are part and parcel of the population. As are every other psychiatric disorder, including and especially depression and PTSD. The difference is that I don’t turn it into a value judgement (i.e. drug users=bad people, but rather drug user=sick person).

      My colleagues used to do their best to ignore patients with substance abuse, because they were the “other.” The only silver lining in the prescription drug abuse cloud is that physicians are now literally being forced to recognize that these folks are THEIR patients, members of THEIR families, and even that they have contributed to the problem. It was my hope that this would literally force them into learning something about behavioral medicine and develop the skills and behaviors needed to treat them. So far, ain’t seen much of that.

      Have seen several patients with mitochondrial dysfunction, and all of them took years to get a diagnosis and were treated similarly to your treatment. Good luck and am glad it is doing somewhat better.

      • DoubtfulGuest

        Thank you. No need to defend your care strategy, this all makes good sense. Perhaps we could make better provisions for mental health care in this country if there was an appropriate demand for it, i.e. even higher than it already is. Since as you mention, many folks attempt to treat their psychic pain as a physical illness, in part due to undeserved stigma.

        It’s possible I misinterpreted your first comment. I just wasn’t sure if in your practice, you 1) start with a population of folks who use, or at least request, opioids, and then screen for trauma history in order to offer psychological intervention or 2) screen a general patient population for trauma history and if it’s positive, then assume a predisposition toward opioid dependence or other problematic behaviors. It sounds like Scenario #1, if your focus is Addiction Medicine

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