The opioid epidemic has become a national emergency. Opioid related deaths have increased ~300% from 2001 to 2016. It is known that overdoses are a leading cause of accidental death in the United States, and the number has been increasing yearly from 2002 to present time. Drug overdoses cause more deaths than car accidents and gun violence. In 2016, 42,000 accidental deaths were from opioids (out of 64,000 total deaths from overdoses of all drugs counted together). About 15,000 of those deaths were from heroin overdoses and about 17,000 were from overdosing on commonly prescribed medications. Twenty percent of deaths in 24-35 year olds involve opioid drugs. The US now consumes 80% of the world’s opioids.
The opioid epidemic is occurring because of multiple factors: deaths related to overdose, lost employment, effects on families and relationships and the cost for treatment. There are multiple risks for long-term opioid misuse. Mortality from all causes is 10x greater than the general population. There is an increased risk in suicide and violence, as well as 3x greater risk of dying from a car accident. There is a known increased risk in engaging in crime to pay for the substance that is being misused. If a person advances to IV drug use, there is a risk of infection including hepatitis, HIV and endocarditis.
Prior to the 1980s opioids were rarely prescribed. Pain was looked at differently. People used to look at pain with the mantra “What doesn’t kill you makes you stronger”. That view of pain has changed over time and there is more of a drive to stop pain and help the body avoid pain with external means. Also because of concern about addiction, providers were uncomfortable with prescribing opioid medications for patients. In recent years, that view has shifted in large part to pharmaceutical companies providing misinformation about newer pain medications. Some of the myths include that these medications are effective for chronic pain; that no dose is too high, meaning that tolerance is not something to worry about; and that very few patients with chronic pain actually develop an addiction because they are using the medication “correctly”. In reality, after one month of use of opioid pain medications, tolerance develops which increases the risk for addiction. Also addiction can develop even if a patient is taking the medication for an actual pain disorder.
The opioid epidemic is seen by many as a symptom of a faltering health care system. Opioids are prescribed across medical specialties. Most people who are addicted to opioids access their opioids directly or indirectly from providers, not off the street. Studies have shown that people of low socioeconomic status are accessing opioid prescriptions as a “treatment” for non-medical, financial and social problems. So how did we get here?
Providers generally have a fast-paced schedule and it can become challenging to find time to have difficult conversations with patients. The current health care reimbursement system weighs heavily in favor of providers doing procedures and prescribing medications. Additionally, the practice of medicine has moved away from the doctor-patient relationship and has become more based on customer service with a focus on patients liking providers versus trusting them.
The question of where do we go from here involves a longer conversation, but there are some practical steps to start with. It starts with limiting access to opioids to situations when it is appropriate (not effective for certain pain syndromes like fibromyalgia and not needed in every post-operative situation). It is important to prescribe the smallest dose for the shortest length of time (ideally 1 month or less) with careful psycho-education about the use and risks of opioid medications. There is a need for incentives for providers to not prescribe. There is a need for time and training on motivational interviewing for providers to help patients with an addiction become interested in sobriety. There is a need for de-prescribing clinics and providers who understand the need for slow taper off long-term opioid medication use. Ideally, co-location of rehabilitation services and mental health services allows for co-treatment. And there is a need for a chronic care model which brings back the primacy of the doctor-patient relationship as important to healing.
Part 2 of this series will be discussing some of these in more detail.