Relieving the pain reliever crisis

In 1996, OxyContin began heavily marketing their opioid pain reliever to physicians. That first year, sales for the drug reached $48 million. By the year 2000, sales had grown to $1.1 billion. Through a sophisticated marketing plan, OxyContin utilized profiles of individual physicians to find the ones who were already the highest prescribers of opioids and promoted the falsehood that chronic pain could be cured. Within this group, they encouraged a more liberal use of opioid pain relievers, and they particularly promoted OxyContin’s usage in the treatment of non-cancer related pain.

Thus began the opioid epidemic as Oxycontin usage increase nearly ten-fold.

As health care professionals, it’s a hard truth to acknowledge our role in this crisis. While other external influences including aggressive marketing, insertion of pain treatment satisfaction into quality and payment programs have contributed, the responsibility of putting pen to paper for the prescription remains with each provider. Physicians are the source of therapeutic opioids, and also often the source of abused opioids, whether those opioids are being taken for medical reasons, or not. And many people, including some providers, aren’t fully educated on the consequences of prescription opioids. Prescription opioids can be very effective for pain management, but are also highly addictive; having similar abuse potential to that of heroin. Even therapeutic doses carry the risk of accidental overdose and death. The underestimation of these risks by patients and providers alike has contributed to our epidemic.

Much of the strategy surrounding curtailing opioid misuse or overuse has been in trying to eliminate abuse by non-medical users. This however fails to account for the huge percentage of accidental overdoses and addiction rates by those taking opioids for legitimate medical reasons. In fact, opioid overdoses occur more frequently in those who received their prescriptions from well-meaning doctors.  Even when the patient being treated is not the one abusing these drugs, family members and friends receive over 75% of their illicit opioids of abuse from legitimate patients.  The medicine cabinet with leftover pills becomes a risk for the patient, their family and friends.

What this means is a bigger effort has to be made to shift the thinking around prescribing opioids.  Providers must move upstream of the addiction and work to help prevent patients from becoming tolerant and potentially addicted. We must protect their loved ones from the risk of extra pills in the medicine cabinet.

Our initiatives at CHI Franciscan Health have been geared toward limiting the amount of opioids prescribed overall. Through education, guidelines, and by sharing best practices, we’ve helped to standardize the number of pills given to a single person, thus limiting abuse. We’ve set up a database to determine where the most pills are being prescribed so we can also assess how to reduce those numbers.  We’ve also begun the process of establishing a drug takeback program to help remove the extra pills from the medicine cabinet if the patient no longer needs them.

What we’ve been doing to support people already addicted to opioids has been just as important. Rather than simply cutting supply and turning people away, we give them treatment options to help them conquer what will be a lifelong disease. We’ve created a Narcan program to identify patients at high risk for opioid overdose and offer them Narcan, a drug designed to save someone from an overdose. The program also allows the patient or a loved one to obtain a Narcan prescription without having to see a physician. The Emergency Departments have partnered with neighboring clinics to initiate Medication Assisted Therapy directly out of the department to get them started on treatment when they are often the most ready. 

The opioid epidemic is deteriorating our national condition and we as physicians have the power to change that narrative and positively improve the lives of our patients. We must help stop addiction by never starting it. Establishing a standard in the health system, limiting prescription quantities, and educating patients on the risks can begin to arrest the growth of addiction. We must work with those suffering addiction to reduce their risk of overdose and death. Many factors created this global epidemic beyond the individual prescriber, but we can lead the effort to combat this disease together and help our patients, friends, and family.

Sources:

https://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-031914-122957 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/