The opioid crisis. Have you heard of it? Media coverage is quick to tell us about record deaths in our communities from opioids. In 2016, there were 42,000 deaths from opioid overdoses in the United States.1 That's the amount of people that would fit into an average pro baseball stadium! It’s also higher than the amount of fatalities from car accidents (37,461) and fire arms (more than 33,000) in the United States that year.4,5 A quick review of the basics: opioids are naturally occurring or manufactured substances that bind to receptors in our body and result in pain relief. They also work in our brains and cause changes to the brain resulting in addiction, or what we call Substance Use Disorder. Opioids also decrease our breathing rate. Deaths from opioids usually occur because someone who has taken too much, or a normal dose with other medications that do the same thing stops them from being able to breath. So, lots of people are dying. But who are they? People who choose to take their prescription opioids outside the directions prescribed to them? People who choose to mix their prescription opioids with other drugs? People who take street opioids like heroin?
Wouldn’t it be easy if it was just one of these groups? Then we could put those people in a box, because they’re different from us. We could find a solution and call it a day. Right? Not so fast. You probably wouldn’t be reading this if it were. Opioids are highly addictive. Some people have a higher risk, but everyone CAN. Risk factors include: age, dose, genetics, gender, mental health disorders, abuse history (physical or emotional), home environment such as parents use and attitudes, and peer and community influences. We have clear evidence that substance use disorder often starts with legitimately prescribed opioids that are taken longer than is needed. Do you know anyone who’s been prescribed more opioids than they need? Risk also increases when you decide to take a medication outside it’s prescribed purpose, or you increase the dose or frequency from that which is prescribed. Taking opioids with other drugs which slow your respiratory rate increases risk of overdose. Examples include benzodiazepines (Xanax, Ativan and Valium), sleep medications (Ambien, Lunesta, Benadryl) and alcohol. So, unfortunately, we are seeing deaths with each of those groups listed above.
Where do the drugs come from? Well, over 70% of non-medical users of opioids get them from their medicine cabinet. 55% obtained them for free from a friend, 11.4% bought them from a friend or relative and 4.8% got them from a friend or relative without asking. 17.3% obtained them from their physician legitimately and began using the “leftovers” after their acute pain subsided. So, you may be wondering, to paraphrase David Bowie, “how did [we] get here?”. It is a result of a perfect storm (part one) that’s been gathering momentum over the past few decades. Here’s a birds eye view: We have drug companies that developed highly powerful opioids (circa 1980’s), hid the addictive qualities of their products (Circa 1995) and perfected highly effective advertising and promotional campaigns that maximized the prescribing of their products (circa 1960’s).6 Physicians graduate medical school usually with a common goal to ease suffering and do no harm. They also graduate with minimal training in pain. According to one study, physicians in North America receive, on average, less than 10 hours of education about pain.2 This includes all coverage of pain neurobiology, pain pharmacology and major pain-associated conditions such as back pain, headache and visceral pain. Even more striking is that one study reported that Canadian veterinary schools deliver over 80 hours of content about pain. 2 Then we have accrediting organizations for health care institutions who took cues from drug companies that pain was under-treated and they demanded hospitals recognize pain as the “fifth vital sign”. This forced institutions to look at “pain” as an independent problem, which needed independent solutions. Drug companies came up with a scale to measure pain, the numeric rating scale which measures pain on a scale from 1 to 10. Are you following closely? Drug companies worked to create a need: “Undertreated pain”, worked with hospital accrediting organizations to recognize under treated pain as a national health crisis and demanded a call to “Recognize pain as the fifth vital sign”. They created a way to track physicians ability to treat pain: “numeric rating scales” and they came up with a solution: perfectly advertised, highly potent (and advertised as non-addictive) opioids.
What about these people dying? Who are they? According to one source, deaths caused by prescription opioids were over 32,445 in 2016.1 Deaths from heroin was nearly 15,500 in 2016. So, prescription opioids are a huge problem. But we also have a problem with heroin as the rate of heroin deaths has increased 19.5% from 2015-2016.7 And the perfect storm part two? Now we have a large population addicted to prescription opioids. Physicians are currently prescribing less opioids than any time in recent history owing in part to the data on opioid usage and risks, restrictions from insurance companies and local/federal government initiatives.8 Reduced prescribing reduces the supply on the streets and that drives up the cost. Heroin, a nonprescription opioid, is now an attractive option because it’s cheaper and easier to obtain. Unfortunately, the United States is facing the crisis of fentanyl and sufentanyl laced heroin. Fentanyl is a very potent synthetic opioid. Sufentanyl is so powerful, that overdoses have occurred simply by the product absorbing through the skin. Users who are self-dosing heroin with doses that have worked well for them in the past may obtain a supply that contains fentanyl or sufentanyl which greatly increases their risk of overdose.
Large organizations are demanding action in response to the deaths we are seeing with opioids. You may have heard of some of the them: The White House, Centers for Disease Control (CDC), Centers for Medicare Services (CMS), Federal Drug Administration (FDA), the Drug Enforcement Agency (DEA) and Substance Abuse and Mental Health Services Administration (SAMHSA).
So far, nationally, we’ve seen action such as the DEA allowing pharmacies and law enforcement departments to register as “reverse distributors” allowing citizens to return unused opioids to those sites, thereby reducing the number of opioids in our households and on the streets. The CDC published a Guideline for Prescribing Opioids for Chronic Pain (March 2016). Federal funds have been made available for states to increase services for Medication Assisted Treatment, naloxone access and community outreach. The National Institutes for Health is supporting activities to advance research on pain and Substance Use Disorder. And so many others that are in place to help improve access to prevention, treatment and recovery support services. And, there is impact we are realizing now, but it will take years, before we see the full impact of some of these actions and before we have to data which will help drive future actions and initiatives.
Craig Hospital has taken several steps to minimize opioid risk. Our providers receive periodic education about opioids. We evaluate opioid Substance Use Disorder risk on patients as they are admitted. Pharmacists are tracking how much patients are using during their stay and that is reported to the physicians on a regular basis and we are all stewards in ensuring opioids aren’t taken at higher doses than is needed and for longer periods of time than is needed. Craig will be launching a Naloxone program this year where graduates leaving Craig at discharge who have a prescription for an opioid will also get a prescription or access to a naloxone product. Naloxone is a reversal agent for opioids and can provide life-saving therapy quickly in the event of an overdose.
There are steps you can take as well to help ease the opioid crisis.
- Utilize drug take back days. There are designated pharmacies or law enforcement agencies that have a program where you can drop off your unused opioids for disposal. If you have left over opioids from a prescription and you no longer need those medications, then dispose of them at a designated pharmacy or police station.
- Talk about opioid use in your household. Have the conversations about the Substance Use Disorder history in your family. Have family members struggled with Substance Use Disorder? How did they cope? How did the family cope? How did the Substance Use Disorder start? What would you/they do differently knowing about Substance Use Disorder? These conversations are crucial for self-reflection and especially for children to start learning the risks involved in drug use. If you have opioids in the home talk about the risks with your children.
- Find out how to become involved at the state or federal level to help pass legislation that can increase public awareness, help institute harm reduction strategies like naloxone programs, increase provider education, lobby for mental health services for those who are seeking help etc.
Heather Smith PharmD. BCPS.
- For a Drug Take Back location near you: call your local law enforcement office
- SAMSHA’s national helpline 1-800-662-HELP (4357). A free confidential 24/7, 365 day-a-year treatment referral and information service (In English and Spanish) for individuals facing mental and/or substance use disorders.
- For SAMSHA funded projects in your state: https://www.samhsa.gov/sites/default/files/grants/pdf/other/ti-17-014-opioid-str-abstracts.pdf
- Seth P, Rudd R, Noonan, R, Haegerich, T. Quantifying the Epidemic of Prescription Opioid Overdose Deaths. American Journal of Public Health, March 2018;108(4),e1-e3.
- Murinson B, Gordin V. Recommendations for a new curriculum in Pain Medicine for Medical Students: Toward a Career Distinguished by Competence and Compassion. https://academic.oup.com/painmedicine/article/14/3/345/1859130 (Pain Medicine Volume 14, issue 3 march 2013) [Accessed May 22, 2018]
- Jones et al. JAMA 2013; and CDC/NCHS 2010.
- Hauser,C. Gun Death Rate Rose Again In 2016, CDC says. New York Times. Nov 4, 2017 https://www.nytimes.com/2017/11/04/us/gun-death-rates.html (Accessed 5-23-2018)
- USDOT Releases 2016 Fatal Traffic Crash Data. National Highway Traffic Safety Administration. Published October 6, 2017. https://www.nhtsa.gov/press-releases/usdot-releases-2016-fatal-traffic-crash-data [Accessed 5-23-2018]
- Keefe, P. The Family that built an Empire of Pain. The New Yorker. Published in print October 30, 2017 https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain [Accessed 5-5-18]
- Heroin Overdose Data. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Published January 26, 2017 https://www.cdc.gov/drugoverdose/data/heroin.html [Accessed 05-25-18]
- U.S. Prescribing Rate Maps. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Published July 31, 2017 https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html