This is the fourth and final post in a series on opioids, arguably the largest public health crisis of the early 21st century. The goal is to give context through education and facts to supplement the daily news about overwhelmed neighborhoods, police and emergency rooms battling overdoses. Part 1 can be found here, part 2 here and part 3 here.
In the first part of this series we introduced the opioid epidemic from the viewpoint of Workers’ Compensation research into the problem which began in earnest at least five years ago. This research was primarily focused on physician prescribing patterns and the growth both in the quantity of prescriptions and the amounts being prescribed, including increases in more potent narcotics such as fentanyl.
The second part defined narcotics and the concept of morphine equivalent doses or MEDs (also known as morphine equivalent amounts, MEAs, and morphine milligram equivalents, MMEs). Additionally, we looked at the general pharmacology of opioids and finally we discussed three factors contributing to the narcotic problem:
Part three was an extremely brief look at stories of overdoses and deaths easily found in the daily news and on medically oriented websites. In addition, we pointed out a just published study on the opioid epidemic through the lens of private health insurance.
This final post looks at the actions that are being taken and that can be taken to stem the tide of addiction and abuse and restore well-being to individuals and their communities. Not surprisingly, much of this centers on providers and their patients. But we should keep in mind we each have a role—these providers and patients are our friends, family and colleagues.
In late August the Surgeon General took the unprecedented step of sending a letter to all providers—about 2.3 million physicians—addressing the opioid crisis. The letter (and a good deal of other information) can be found at Turn the Tide Rx. Here is the second paragraph of the letter, commenting on the issues we discussed previously:
It is important to recognize that we arrived at this place on a path paved with good intentions.
Additionally, the letter mentions a CDC report that indicates no real increase in pain-related diagnoses that might account for some of the epidemic. Finally, the letter was sent including a pocket-card summary of the CDC Opioid prescribing guidelines.
The card can also be found on the Turn the Tide website along with two other useful summary cards—much easier to read than the technical prescribing guidelines. The first card discusses non-opioid pain treatments for chronic pain. One thing we have not addressed very well in this series is the kinds of pain for which opioids are and are not appropriate. Opioids have a place in the treatment of moderate to severe acute episodes of pain as well as in cancer treatment, palliative care and end-of-life care. The evidence is mixed for the long term use of opioids to treat chronic pain (chronic is defined as greater than 3-months).
Non-narcotic options include non-drug options: changes in diet, mindfulness, massage, physical therapy, activity and cognitive behavioral therapy, among others. Non-steroidal anti-inflammatory drugs (NSAIDS) such as aspirin, ibuprofen and naproxen can be obtained over-the-counter and some can be taken at “prescription” level doses—with a doctor’s advice of course. Acetaminophen is not an NSAID and should not be taken at doses higher than recommended as it is proven to cause liver damage. Many prescription narcotics are combination products that contain acetaminophen which should be taken into account. The FDA has a small and helpful piece oriented towards patients and consumers that covers some of this information.
Other non-narcotic possibilities discussed are tricyclic antidepressants (e.g. amitriptyline), serotonin and norepinephrine reuptake inhibitors (SNRIs, e.g. duloxetine) and anticonvulsants (e.g. gabapentin). Note that many of these should not be taken along with opioids due to serious side-effects.
Helios, a workers’ comp subsidiary of Optum recently published the second-edition of their Clinical Info newsletter which discusses some of the information supplied above. The newsletter begins with a state-by-state discussion of actions being taken in the WC industry to curb the misuse and abuse of narcotics. Many states are mandating the use of PDMPs (prescription drug monitoring programs). This is true for both WC and for group health.
These are databases that doctors are required to check for existing prescriptions their patients may have received from another doctor. Here in CA Gov. Brown just signed a bill mandating that the existing database be used when a doctor is going to prescribe a controlled substance. Health Affairs recently published a study showing an association between a reduction of opioid-related deaths and PDMPs.
Other states are putting regulations in place that limit the quantities of an opioid that can initially be prescribed for acute pain, say after surgery, or for chronic pain. Another option being pushed, both by the Surgeon General and in WC is lower doses since it has been shown that abuse and addiction risks increase at higher doses while there is some evidence that the associated pain relief does not.
Not only do prescribers need to learn best practices but individuals need to begin to understand that prescription drugs for pain are not curative but simply symptom relievers and that there are other—non-addictive—possibilities. There is no doubt that severe or chronic pain can diminish quality of life. However, there is some evidence that opioids can make pain worse. It is our responsibility to question our doctors and to demand that they too learn about all of the pain-treatment options available.
Some researchers are working on non-addictive pharmaceuticals for pain relief. While this is hopeful it still ignores the reality of pain and the possibility of non-pharmaceutical solutions. The website, PainAction.com, while partially sponsored by at least one drug company, is oriented towards people who suffer from various forms of chronic pain and supplies helpful educational materials as well as links to other resources.
And what of the companies who manufacture narcotics? Past efforts have focused on “abuse proof” formulations meant to deter abuse by preventing crushing and dissolving for snorting or injection, for example. But the evidence for adequate deterrence is not conclusive. The search for non-addictive pain medication, as we indicated above continues.
In the meantime, it seems that the pharmaceuticals not only are not really participating in resolving the opioid epidemic but are actively working against us with lobbying, campaign contributions and ongoing aggressive sales tactics. They continue to lobby against legalization of marijuana even though there is evidence of a decrease in opioid use and abuse in states that have legalized it.
Despite this there is still hope. West Virginia, one of the hardest hit states in the country has taken the steps to create a consortium “of pain specialists, pharmacists, and health-insurance representatives with the goal of taking on opioid over prescription and abuse in the state.”
As Business Insider reports, “According to Dr. Timothy Deer, the CEO of the Center for Pain Relief and the other cochair of the panel, the team is focused on achieving three goals:
In a similar, but broader vein, Deloitte University Press recently published an extensive article called Fighting the opioid crisis: An ecosystem approach to a wicked problem (also available as a pdf). By looking at other crises they have found that successful resolutions frequently come from “a solution ecosystem” consisting of:
This approach, they write:
could become the best hope in the battle against opioid addiction. From engaging new partners in the fight and aligning action across the ecosystem, to using a portfolio of interventions, driving innovation, and using markets to support sustainable solutions, the ecosystem is likely to generate the most powerful response. This collaborative approach inspires all stakeholders—across the boundaries of public health, criminal justice, economic development, and human services—to act as a single, integrated community and point the way toward powerful new solutions.
In short, we are all in this together, we all have a role to play by being responsible providers, patients and community members.
The Opioid Crisis among the Privately Insured, and The Impact of the Opioid Crisis on the Healthcare System—A Study of Privately Billed Services,
Links not cited:
Jesse Sharp is an expert in the analysis of health care data. Passionate about data and the ethics of analysis he writes on topics related to medicine, public health and statistics. More...