No Easy Fix to Opioid Abuse-Related Problems

While death and abuse rates from prescription opioids are dropping, death rates from heroin use are going in the opposite direction.

Behind every apparent bit of progress in healthcare lurks disaster.

First the progress, which is indeed good news: drug diversion and abuse of prescription opioids, which saw a horrifying increase over the last decade, have plateaued and even declined, according to research published in the New England Journal of Medicine and by the Centers for Disease Control and Prevention last month.

There’s a handful of reasons why, including major initiatives by state and federal governments, and “abuse-deterrent” oxycodone formulations that block euphoric effects when the drug is crushed, snorted, or dissolved, says Richard Dart, MD, director of the Rocky Mountain Poison and Drug Center of the Denver Health and Hospital Authority.

Another extremely effective strategy has been the adoption in 49 states of prescription drug monitoring programs, or PMPs. [Missouri is the holdout.] These are databases that pharmacists and prescribers can check to see if a patient has recently filled an opioid prescription, potentially revealing a pattern of doctor shopping, says Dart, who is trained in emergency medicine and toxicology.

Those states now push pharmacists to report controlled substance prescriptions they’re asked to fill. Some, such as Colorado, even send follow-up notification letters to patients’ physicians, “in case the doctors didn’t check the list themselves, to say ‘this patient stands out, and you should pay attention; there’s something wrong with this prescription pattern,'” Dart says.

Whac- a-Mole

But as with many newly found solutions, there is a dark side to this progress. It is, Dart acknowledges, like the old arcade game, whac- a-mole: A problem that is being successfully managed in one way is tenaciously popping up somewhere else.

It turns out that an awful lot of people, thwarted from obtaining prescription drugs such as oxycodone, fentanyl, and morphine, are instead turning to high-purity, low-cost heroin. While death and abuse rates from prescription opioids are dropping, death rates from heroin are going in the opposite direction, Dart says.

It’s not clear why, but Dart, lead author of the NEJM paper, suggests one reason, which he says all drug policy makers and law enforcement personnel should consider because it has the potential to subvert their efforts and resources.

Addicted the First Time

“When I was training in the ’80s, I was taught that if you treated a patient appropriately, gave them a reasonable dose of an opioid [for] real pain like a fracture, and said ‘take that while we’re waiting for the orthopod—I was told no onegets addicted. I was actually taught that and medical students are still taught that, because that’s what audiences tell me when I give talks.

“But it’s not true,” he says.

“If you ask anyone who treats substance abuse, they will tell you so. A certain portion of the population is susceptible to opioids, like an emergency medicine doctor I knew in training.” They get addicted even after the first time they take it.

“One day he was arrested. He’d had an orthopedic procedure and received Vicodin. He told me that ‘From the moment I took it I knew I had to have this drug. I loved this drug.’ He started prescribing it for himself, and he got caught.”

What is true, Dart says, is that a small number—it’s probably only about 1%—of people treated with opioids will become addicted with the first dose. But that still could mean “tens of thousands” of new addicts who may have been protected with more judicious prescribing.

The Push to Prescribe for Pain

While federal and state policy changes have helped trim opioid abuse, other government programs might be making the problem worse. For example, in patient experience surveys three questions concern how well providers managed patients’ pain. A typical question: “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?”

“There’s huge pressure,” Dart says. “Even The Joint Commission, when it comes to our hospital [for accreditation reviews] looks at charts and asks, ‘did you do a pain score for these patients? And what did you do if they told you they had pain?’ ”

Surveys and policies like these make doctors afraid to say no, Dart says. “It’s gotten to the point where everyone is afraid of the surveys. Doctors are saying to themselves, ‘I’d better give you a prescription even if I’m not sure you’ll need it.’ ”

Prophylactic Prescribing

Some surgeons and dentists, Dart adds, automatically and prophylactically give patients opioid prescriptions to take, “in case” they develop pain.

These policies and practices send a contrary message than the one that should be sent.

True, the PMP databases are helping a lot, and giving doctors evidence they need to resist. But doctors should spend more time talking with patients to see if they can handle some level of pain without a drug rather than automatically handing over a prescription.

Dart says guidelines on responsible prescribing from medical professional societies, educational initiatives, the closure of pill mills in states such as Florida, and funding of treatment centers for people who get in trouble, have helped enormously.

Also publicity surrounding the opioid-related deaths of celebrities such as Michael Jackson and Heath Ledger may have spread the word that opioids aren’t always safe.

“Awareness has increased dramatically, and doctors write [fewer] and smaller-dose prescriptions than they used to,” Dart says.

Still, actor Philip Seymour Hoffman died last year from an accidental overdose of drugs. Heroin was one of them.

Policy makers should take care to realize that “[even] if we stop susceptible people who need to have these drugs, as we’re doing right now… they’re not going to stop. They will switch to something else… like heroin,” Dart says. “That’s what’s fueling the increase in heroin deaths.”