Opioid crisis: What can be done?
Public health authorities have described, with growing alarm, an unprecedented increase in morbidity and mortality associated with use of opioid pain relievers (OPRs). Efforts to address the opioid crisis have focused mainly on reducing nonmedical OPR use. Too often overlooked, however, is the need for preventing and treating opioid addiction, which occurs in both medical and nonmedical OPR users. Overprescribing of OPRs has led to a sharp increase in the prevalence of opioid addiction, which in turn has been associated with a rise in overdose deaths and heroin use. Recent tragic deaths of celebrities, most recently Prince, have brought this ever growing epidemic into the spotlight. Several factors are associated with this trend in medicine.
It is the prescribing provider’s responsibility to make sure checks and balances are in place before prescribing opiates. This begins even before the initial encounter. Virtually every state has a form of prescription data monitoring to track opiate prescriptions. This has proved a great way to both monitor compliance with what has been prescribed as well as to discover a patient that may be doctor shopping. There is an important limitation to this, however—not all states share the data. A patient can easily go to a neighboring state and present with legitimate pain along with supporting diagnostic testing and receive yet another prescription. The governing body, the DEA, should develop a central database that accounts for any prescription written for controlled substances. New York State has mandated that all prescriptions be sent electronically. If other states follow suit, it will make a central database easier to compile.
An appropriate risk assessment screening process needs to be in place to determine whether a patient is at higher risk for potential abuse and diversion of medication. This is partially achieved with in-office toxicology testing to screen for illicit drug use.
Opiate medications are, by their nature, addictive. This must be discussed with every patient prior to initiating treatment. It behooves a physician prescribing opiates to set a threshold dose that will not be exceeded. Should a patient be non-compliant with the treatment, or display signs of developing addiction and dependence, a physician should, without fear of labeling the patients as an addict, make an appropriate consultation to an addiction medicine specialist sooner than later. This does not abandon the patient but provides a way to treat a developing concern.
There isn’t a simple solution. Each patient is an individual and has to be treated with a tailored regimen. Each doctor practices a certain style and may be comfortable with higher doses of opiate medications. But yet, they are both met with aforementioned challenges. Together, through the collaborative efforts of doctors by establishing and adhering to guidelines, pharmacies to properly report to state prescription monitoring agencies, the DEA through better control and regulation of illegal sources of medications entering the market, and, very importantly, patients taking responsibility, in a combined effort to combat this opiate-related death epidemic, we can prevail in this contemporary war on drugs.