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11 YEARS LATER: THE WORSENING OPIOID EPIDEMIC

TASA ID: 13340

Eleven years ago, I wrote the article, “Perils of Pain Meds,” with a plea to the medical community to reduce opioid over-prescribing which could reduce the mounting toll of morbidity and mortality related to the growing opioid epidemic. Although there has been a greater than 20% decrease in opioid prescribing since 2010 [1,2], recent CDC data show that the total opioid-related death rate has significantly increased [3], driven by a rising population with the potentially fatal brain disease of opioid addiction [4], many of whom turn to heroin, often laced with deadly fentanyl or its more powerful analogs [5] which greatly increase opioid potency and attractiveness to addicts. Eighty percent of heroin addicts first start with prescription opioids, often for some type of pain [4], before turning to much cheaper heroin bought on the streets when they are no longer able to obtain opioid prescriptions from their providers.

Tragically, the percentage of people receiving treatment for addiction is very low; well below 20% with frequent relapses in those fortunate enough to receive treatment. This only adds to our rising population with the disease of opioid addiction, spanning the spectrum from prescription opioids to heroin to fentanyl and its analogs. The result has been a nightmare of mortality statistics related to opioid drug use which continues to grow. Data from the National Center of Health Statistics from 2016 revealed the following: 116 opioid-related deaths per day, with deaths by opioid category per year of over 17,000 from prescription opioids, over 15,000 due to heroin and over 19,000 from synthetic opioids [mainly fentanyl and its analogs], while the economic costs were estimated at a staggering 504 billion [6].

Therefore, every effort must be made by the medical community to prevent iatrogenic opioid addiction and opioid-related deaths, which needs to start with a much greater reduction in opioid prescribing for chronic non-cancer pain [CNCP]. 

As per a major NIH study published in 2015, prior to the above data, opioids have never been shown to be effective long-term for CNCP, while there is definite evidence for accumulating harms which are dose-related [7]. This study, along with others, as well as input from our group, Physicians for Responsible Opioid Prescribing or PROP, helped establish the 2016 CDC Guideline which significantly limits opioid prescribing for CNCP while emphasizing instead non-opioid, multidisciplinary management strategies utilizing a biopsychosocial approach [8]. These are similar techniques which I wrote about in the aforementioned 2008 article, that include patient education, self-help courses, physical therapy, regular home exercise programs, and psychological/behavioral approaches to pain management.

For many years, well-before the “rush-to-opioids” movement, these non-opioid therapies were promoted for rheumatic disorders by the internal medicine subspecialty of rheumatology. This is in stark contrast to the field of pain management which initially was overly-focused on opioid therapy for CNCP which facilitated the opioid epidemic starting with the launch of OxyContin by Purdue Pharma in 1996. Currently, this and other opioid manufacturers of the opioid pharmaceutical industry, which used a campaign of deception,  misinformation and pseudoscience in a very successful opioid marketing strategy [9], is the subject of multiple lawsuits filed by at least 30 state attorney generals, and more than 1200 cities, counties and municipalities throughout the nation, in response to the staggering economic and social costs which have accrued as a result of the rising volume of opioid addiction and death [10].

The reality of medical practice today is that too many providers are still “flying blind” [11] in relation to the proper diagnosis and treatment of CNCP for which opioids continue to be over-prescribed, in addition to the frequent failure to recognize opioid-related adverse effects including the presence or onset of opioid addiction in the large patient population already on opioids which continues to fuel the opioid epidemic. Much too often, it is easier to maintain these patients on opioids indefinitely, rather than make the more difficult choices of either gradual opioid dosage reduction or eventual discontinuation [which often results in various levels of withdrawal reactions], or to make referrals for addiction treatment services, including the use of buprenorphine, a great unmet need in medicine today which could save numerous lives.

Families of patients who have died from or have become addicted to opioids as a result of inappropriate prescribing are now seeking legal means for economic compensation for their trauma and/or loss of loved ones. Each individual case requires expert medical evaluation, especially to determine provider deviation from current standards of care as per the 2016 CDC Guideline, or for veteran and eligible military patients at VA or military facilities, similar opioid prescribing guidance issued by the U.S. Department of Veterans Affairs [VA] and the Department of Defense [DoD]. This often includes looking into the actual reason why opioids were prescribed initially and whether or not they were indicated for CNCP in lieu of non-opioid options, and whether or not symptoms and signs of opioid addiction or other opioid-related adverse effects were present and missed.

In addition to the role of physicians in opioid over-prescribing, there are many instances in which health care administrators have put pressure on doctors through their job security status to adhere to a “business model” which often involves less cautious opioid prescribing for achieving good patient “satisfaction” scores on pain control surveys. This should also place these facilities in the cross-hairs of any litigation involving unnecessary patient deaths due to inappropriate opioid prescribing.

Since common types of CNCP include the rheumatic disorders of arthritis and fibromyalgia, rheumatology expertise is often an essential part of these evaluations. I am available through TASA for this purpose, which includes medical chart reviews to determine the quality and appropriateness of the medical care of patients who have either died from or who have been harmed by opioid painkillers, especially if prescribed for rheumatic causes of CNCP.

The author/expert, MD, FACP, rheumatology consultant, member of the Physicians for Responsible Opioid Prescribing [PROP] (www.supportprop.org).


TASA Article Disclaimer

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

This article may not be duplicated, altered, distributed, saved, incorporated into another document or website, or otherwise modified without the permission of TASA and the author (TASA Id#: 11340). Contact marketing@tasanet.com for any questions.

___________________________

REFERENCES:

1] Guy GP, et al. Vital Signs: Changes in opioid prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017; Jul 7; 66[26]:697-704.

2] Harris PA. AMA: Opioid prescriptions drop 22% nationally. Healio Rheum. 2018; Jul 3[7]:56.

3] Rudd RA, et al. Increases in drug and opioid-involved overdose deaths- United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016; Dec 30; 65[50-51]:1445-1452.

4] Kolodny A, et al. The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annu Rev Public Health. 2015; 36:559-74.

5] Seth P, et al. Overdose deaths involving opioids, cocaine and psychostimulants- United States, 2015-2016. MMWR Morb Mortal Wkly Rep. 2018; Mar 30; 67[12]:349-358.

6] Mortality in the United States, 2016 NCHS Data Brief No. 293, December, 2017.

7] Chou R, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: A systemic review for a National Institutes of Health pathways to prevention workshop. Ann Intern Med. 2015; 162:276-286.

8] Frieden TR, Houry D. Reducing the risks of relief- The CDC Opioid Prescribing Guideline. N Eng J Med. 2016; 374:1501-1504.

9] Van Zee A. The promotion and marketing of OxyContin: Commercial triumph, public health tragedy. Am J Public Health. 2009; February; 99[2]:221-227.

10] Walters J. Sackler family members face mass litigation and criminal investigations over opioid crisis. The Guardian November 19, 2018.

11] Von Korff M, Deyo RA. Potent opioids for chronic musculoskeletal pain: flying blind? Pain. 2004 Jun;109[3]:207-9.

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