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The Opioid Crisis
Editorial
The Opioid Crisis
The recent letter from the United States Surgeon General concerning the alarming crisis in the abuse of prescription opioids should be a wake up call for all of us. There has been widespread societal recognition of the problem, particularly in the regions that have been hit the hardest. Presidential primary voters in many states listed drug addiction as their most important concern. Both the National Governors Association and Congress have worked in a bipartisan fashion to address the crisis. As a result, the regulatory environment has been rapidly changing in response to these concerns. The most important of which is the human toll. In 2014, the United States reported the number of accidental deaths from opioids were one and a half times greater than those caused by traffic accidents (1). I had to read that sentence twice when I first read it. Opioid prescriptions dispensed by retail pharmacies in the United States have quadrupled since 1999 (2). Overdose deaths have also quadrupled since 1999, killing more than 16,000 people in the United States in 2013 (3). In Pennsylvania along, 2,500 people in died from drug overdoses in 2014, and one in four families has been affected in some way (4). The nonmedical use of prescription opioids is also a strong risk factor for heroin use (5). In many cases, the addiction begins with a prescription opioid. As the cost of prescription opioids rise, those with opiod addiction turn to heroin as a cheaper alternative. A 2015 study in the Journal of Hospital Medicine identified that patients on high opioid doses have a 41-51% greater risk of hospitalization if on opioids for longer than three
months and an increased risk of longer inpatient stays over the next six months (6). How did we get to this position so quickly? The answer is complex, but in 1996, when the Pain Society called pain “the fifth vital sign”, there was an increased emphasis on managing patient’s pain. That emphasis was incorporated into Joint Commission language and CMS language on measuring patient satisfaction with their pain control. The introduction of OxyContin also occurred, which became a source of abuse by addicts who could easily obtain and abuse the drug to achieve a quick high. In 2007, Purdue Pharmaceuticals settled for $600 million dollars in fines and payments (some $470 million in fines to federal and state agencies and $130 million in payments to settle civil litigation) because of the abuse potential of the medication. Additionally, three of the executives pleaded guilty to misbranding, which is considered a criminal violation (7). By 2016, many specialty societies requested CMS to reconsider the language regarding pain control. We cannot control this epidemic, but there are certainly ways that each of us can contribute to its demise. Temple University Hospital emergency room physicians developed and implemented an opioid prescribing guideline that resulted in a reduction of opioid prescriptions (8). With parity as physicians comes responsibility to help eradicate this public health crisis. As physicians, we can identify those patients more prone to substance abuse, particularaly those already taking benzodiazepines. Other indicators include alcohol and tobacco abuse history, family history of substance abuse and psychiatric disorders, a family history of sexual abuse, current use of illegal substances, and other behavior patterns. It’s critical that we document all patient interactions, including assessments, test results, and treatment plans, and perform a thorough evaluation and assessment of possible etiologies for pain. Simple opioid risk tools can be utilized where there is an index of suspicion for abuse potential. Many states have online databases to allow for screening of patients who might be receiving prescriptions from multiple prescribers. One at-risk population is the elderly. A 2014 study documented that Medicare patients received opioids from two providers in over 36% of cases, 14.2% from three providers, and 11.9% from four or more prescribers (9). An increased number of prescribers results in an increased likelihood of hospitalization. Older patients are more likely to suffer from the constipation side effects of opioids, respiratory depression is more likely, and smaller starting dosages are often necessary in debilitated, non-opioid tolerant patients. General principles include: 1. Conduct a thorough history and physical including psychiatric status and substance abuse history. 2. Consider non steroidal anti inflammatory drugs as first line medications unless contraindicated. 3. Opioids should be used for the shortest duration and at the lowest effective dose. 4. Have a preoperative discussion with patients about pain medications and their risks, including your expectations for how long medication may be necessary. 5. Antidepressants, benzodiazepines, and other sedating medications increase the risk of serious adverse effects.
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.10.002
2
Editorial / The Journal of Foot & Ankle Surgery 56 (2017) 1–2
6. Monitor total acetaminophen doses and patients with sleep apnea. 7. Use state drug monitoring programs, whether mandatory or voluntary.
Foot and ankle surgeons can make a significant contribution to the reduction of this public health problem. Physician and patient education is the first step. Kieran T. Mahan, DPM, MS, FACFAS Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA References 1. CDC. Wide-ranging online data for epidemiologic research (WONDER), CDC, National Center for Health Statistics, Atlanta, GA. Available at: http://wonder.cdc.gov; 2015. Accessed October 10, 2016.
2. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?scid¼ mm6043a4w#fig2. Accessed October 10, 2016. 3. Centers for Disease Control and Prevention. National Vital Statistics System mortality data. 2015. Available at: http://www.cdc.gov/nchs/deaths.htm. Accessed October 10, 2016. 4. Pennsylvania State Coroners Association. Report on Overdose death statistics. 2014. Available at: http://pacoroners.org. Accessed October 10, 2016. 5. Compton W, Jones C, Baldwin G. Relationship between Nonmedical PrescriptionOpioid Use and Heroin Use N. Engl J Med 374:154–163, 2016. 6. Liang Y, Turner B. NationalCohort Study of Opiod Analgesic Dose and Risk of Future Hospitalization. J. Hospital Medicine 10:425–431, 2015. 7. Meir B. In Guilty Pleas, OcyContin Maker to Pay $600 Million. The New York Times; May 10, 2007. 8. del Portal D, Healy M, Satz W, McNamara R. Impact of an opioid prescribing guidline in the acute care setting. J Emergency Med 50:21–25, 2016. 9. Jena A, Goldman D, Weaver L, Karaca-Mandic P. Opiod prescribing by multiple providers in Medicare: retrospective observational study of insurance claims. BMJ 348:g1393, 2014.
The Opioid Crisis
The recent letter from the United States Surgeon General concerning the alarming crisis in the abuse of prescription opioids should be a wake up call for all of us. There has been widespread societal recognition of the problem, particularly in the regions that have been hit the hardest. Presidential primary voters in many states listed drug addiction as their most important concern. Both the National Governors Association and Congress have worked in a bipartisan fashion to address the crisis. As a result, the regulatory environment has been rapidly changing in response to these concerns. The most important of which is the human toll. In 2014, the United States reported the number of accidental deaths from opioids were one and a half times greater than those caused by traffic accidents (1). I had to read that sentence twice when I first read it. Opioid prescriptions dispensed by retail pharmacies in the United States have quadrupled since 1999 (2). Overdose deaths have also quadrupled since 1999, killing more than 16,000 people in the United States in 2013 (3). In Pennsylvania along, 2,500 people in died from drug overdoses in 2014, and one in four families has been affected in some way (4). The nonmedical use of prescription opioids is also a strong risk factor for heroin use (5). In many cases, the addiction begins with a prescription opioid. As the cost of prescription opioids rise, those with opiod addiction turn to heroin as a cheaper alternative. A 2015 study in the Journal of Hospital Medicine identified that patients on high opioid doses have a 41-51% greater risk of hospitalization if on opioids for longer than three
months and an increased risk of longer inpatient stays over the next six months (6). How did we get to this position so quickly? The answer is complex, but in 1996, when the Pain Society called pain “the fifth vital sign”, there was an increased emphasis on managing patient’s pain. That emphasis was incorporated into Joint Commission language and CMS language on measuring patient satisfaction with their pain control. The introduction of OxyContin also occurred, which became a source of abuse by addicts who could easily obtain and abuse the drug to achieve a quick high. In 2007, Purdue Pharmaceuticals settled for $600 million dollars in fines and payments (some $470 million in fines to federal and state agencies and $130 million in payments to settle civil litigation) because of the abuse potential of the medication. Additionally, three of the executives pleaded guilty to misbranding, which is considered a criminal violation (7). By 2016, many specialty societies requested CMS to reconsider the language regarding pain control. We cannot control this epidemic, but there are certainly ways that each of us can contribute to its demise. Temple University Hospital emergency room physicians developed and implemented an opioid prescribing guideline that resulted in a reduction of opioid prescriptions (8). With parity as physicians comes responsibility to help eradicate this public health crisis. As physicians, we can identify those patients more prone to substance abuse, particularaly those already taking benzodiazepines. Other indicators include alcohol and tobacco abuse history, family history of substance abuse and psychiatric disorders, a family history of sexual abuse, current use of illegal substances, and other behavior patterns. It’s critical that we document all patient interactions, including assessments, test results, and treatment plans, and perform a thorough evaluation and assessment of possible etiologies for pain. Simple opioid risk tools can be utilized where there is an index of suspicion for abuse potential. Many states have online databases to allow for screening of patients who might be receiving prescriptions from multiple prescribers. One at-risk population is the elderly. A 2014 study documented that Medicare patients received opioids from two providers in over 36% of cases, 14.2% from three providers, and 11.9% from four or more prescribers (9). An increased number of prescribers results in an increased likelihood of hospitalization. Older patients are more likely to suffer from the constipation side effects of opioids, respiratory depression is more likely, and smaller starting dosages are often necessary in debilitated, non-opioid tolerant patients. General principles include: 1. Conduct a thorough history and physical including psychiatric status and substance abuse history. 2. Consider non steroidal anti inflammatory drugs as first line medications unless contraindicated. 3. Opioids should be used for the shortest duration and at the lowest effective dose. 4. Have a preoperative discussion with patients about pain medications and their risks, including your expectations for how long medication may be necessary. 5. Antidepressants, benzodiazepines, and other sedating medications increase the risk of serious adverse effects.
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.10.002
2
Editorial / The Journal of Foot & Ankle Surgery 56 (2017) 1–2
6. Monitor total acetaminophen doses and patients with sleep apnea. 7. Use state drug monitoring programs, whether mandatory or voluntary.
Foot and ankle surgeons can make a significant contribution to the reduction of this public health problem. Physician and patient education is the first step. Kieran T. Mahan, DPM, MS, FACFAS Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA References 1. CDC. Wide-ranging online data for epidemiologic research (WONDER), CDC, National Center for Health Statistics, Atlanta, GA. Available at: http://wonder.cdc.gov; 2015. Accessed October 10, 2016.
2. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?scid¼ mm6043a4w#fig2. Accessed October 10, 2016. 3. Centers for Disease Control and Prevention. National Vital Statistics System mortality data. 2015. Available at: http://www.cdc.gov/nchs/deaths.htm. Accessed October 10, 2016. 4. Pennsylvania State Coroners Association. Report on Overdose death statistics. 2014. Available at: http://pacoroners.org. Accessed October 10, 2016. 5. Compton W, Jones C, Baldwin G. Relationship between Nonmedical PrescriptionOpioid Use and Heroin Use N. Engl J Med 374:154–163, 2016. 6. Liang Y, Turner B. NationalCohort Study of Opiod Analgesic Dose and Risk of Future Hospitalization. J. Hospital Medicine 10:425–431, 2015. 7. Meir B. In Guilty Pleas, OcyContin Maker to Pay $600 Million. The New York Times; May 10, 2007. 8. del Portal D, Healy M, Satz W, McNamara R. Impact of an opioid prescribing guidline in the acute care setting. J Emergency Med 50:21–25, 2016. 9. Jena A, Goldman D, Weaver L, Karaca-Mandic P. Opiod prescribing by multiple providers in Medicare: retrospective observational study of insurance claims. BMJ 348:g1393, 2014.