Why Did the Opioid Epidemic Develop and How Do We Stop It?
During the last 18 years, both the amount of prescription opioids and the number of deaths attributed to these drugs has quadrupled in the U.S., Glenn J. Treisman, M.D., Ph.D., of Johns Hopkins University said in a recent IAS webinar. Overuse of opioids has a long history in this country, starting with patent medications that were prescribed mainly to women in the 1800s, to the drugs' rising popularity with immigrants in the early 1900s, to the United Nation's proclamation of opiates as a "human right" in the 1960s. The current opioid epidemic started in the 1980s and has grown to a massive scale, Treisman noted.
In the 1980s, evidence from acute pain and end-of-life palliative care was applied to prescribing opiates for chronic long-term pain, Bruce M. Psaty, M.D., Ph.D., and Joseph O. Merrill, M.D., M.P.H., explained in a New England Journal of Medicine editorial on the subject. Whether the benefits of opioids for chronic pain outweigh their risks is still unknown, they added. Treisman noted the lack of randomized placebo-controlled clinical trials evaluating the use of these drugs for chronic pain. Studies have shown that longer exposure to such substances increases the likelihood of addiction.
Purdue Pharma, the manufacturer of oxycodone (OxyCotin), spent $10 million to advertise the drug during its first year of sales, increasing that amount to $28 million by the fifth year after the drug was approved in the U.S., Treisman said. This campaign was targeted not only at physicians, but also at consumers. The latter were offered "starter" coupons for a month's worth of free medication, while doctors were courted with all-expenses-paid trainings and pain "education" programs, Psaty and Merrill noted.
The company was eventually fined millions of dollars for misleading promotion of the drug. However, its aggressive sales push is only part of the problem, Treisman explained. Alternative pain relief methods, such as physical therapy, acupuncture or neuromodulators, take longer to take effect and require more intervention from medical care providers than do opioids. Current reimbursement schedules for medical care favor "quick and easy" solutions, such as prescriptions, over these more time-consuming and more expensive interventions, he noted.
Insurance payments are also increasingly based on patient satisfaction scores, which are based on questionnaires asking, among other questions, whether any pain was "always promptly" treated by staff. Treisman cited a 2012 statistic that showed increased patient satisfaction rates correlating with increased mortality rates. Shortly thereafter, Medicare started to base hospital payments in part on patient satisfaction. "This means essentially that the Medicare payments are linked to increased mortality -- not necessarily a good approach," he commented. A 2015 survey of physicians in Florida and Georgia found that 40% either had been disciplined themselves or knew a colleague who had been disciplined for not providing an opioid prescription to a patient who requested it.
Current opioid users cannot simply be stopped "cold turkey," though. Data from the Centers for Disease Control and Prevention show that a decline in prescription rates for oxycodone extended release (OxyCotin XR) in several states, including New York, correlated with increased death rates from non-prescription opioids, such as heroin. A 2009 analysis of urine drug screenings among more than 900,000 people who were prescribed opioids for chronic pain also showed that many were taking the medication incorrectly. This included more than a third without the prescribed drug in their urine samples and a quarter with higher drug levels than they should have had, as well as more than a quarter using medication that was not prescribed for them and more than a tenth testing positive for street drugs.
Now that we have defined the problem, how do we solve it? "We want to get people off narcotics and into good care. But, in order to do that, we need collaborative treatment," said Treisman. "Every HIV clinic in this country should have mental health and substance use treatment in it; every substance use clinic in this country should have mental health, HIV and hepatitis C treatment in it; and every mental health clinic should have both substance use and HIV and hepatitis C care in it." In addition, Psaty and Merrill advocated, "The FDA [U.S. Food and Drug Administration] should have the power to limit or prohibit prescriber profiling and off-label promotion, as well as the use of coupons or other forms of direct-to-consumer marketing."