In a little over 200 years, opioids went from being a promising new discovery to a killer whose fingers reached into every walk of life, killing unsuspecting victims from all socioeconomic classes. Morphine was first created from opium in 1804, and in 2008 drug overdoses, primarily caused by opioids, surpassed car accidents as the number one cause of accidental death in the United States. The saddest part of this whole story is that we, as prescribers, are largely responsible for this crisis reaching epidemic proportions. That’s not to say we have done it intentionally. As healthcare practitioners, we innately want to ease people’s suffering. That need is paired with modern day society’s demand of a quick fix. Patients often want a pill that will make them feel better, and we are sometimes all too willing to oblige. When the prescription runs out, and refills are denied, patients may seek illegal means of obtaining a continued supply of pills.
As for myself, I can honestly say that, until this past year, I had no idea how large a role prescription opioids and healthcare practitioners played. Being on a cardiac surgery service where I am most often only dealing with acute, post-surgical pain, likely made me naïve to the enormity of the problem in the outpatient setting. Another big contributor to this problem is the fact that government agencies have tied good pain control scores to hospital reimbursement. A system like this practically promotes over medication, however, it is now our job to turn the tide and be creative. We can continue to treat our patients’ pain. Perhaps we just have to try harder, and offer more adjunctive therapies and resources, rather than just check the box and order the standard pill.
Living in Virginia, I recently attended a lecture given by Dr Barbara Allison-Bryan, Chief Deputy, Virginia Department of Health Professions. She presented some startling statistics from the National Institute on Drug Abuse, and the Virginia Department of Behavioral Health and Developmental Services. Eleven percent of high school seniors admit to non-medical use of prescription opioids. Drug over dose is the leading cause of death in the United States for those between the ages of 25 and 45. Every 12 hours a resident of Virginia dies from an opioid overdose. A final staggering statistic is the fact that Virginia spends $546 million annually on healthcare related to opioid abuse. I can only imagine that most states have similar data. Reading these statistics opened my eyes to how big this problem has become.
So the question remains, what can we do? While this topic is overwhelming, I’ve thought a lot about it and have come up with three first steps. First, even if it is not mandated by your state, look into your state’s Prescription Monitoring Program (PMP), create an account, and start using it. For any who are unfamiliar with this, the PMP is a 24/7 database containing information on dispensed Schedule II-IV prescriptions and drugs of concern. Currently, 49 states and the District of Columbia have a monitoring program that is operational. Many of these monitoring programs are connected to other states. For example, Virginia’s PMP is connected to 29 other states and to the District of Columbia. Creating an account with the PMP will let you know, in many cases, if a patient is being prescribed opioids from another provider. A second step is to work with your institution, or your service, to create an algorithm for pain control that abides by your states’ regulations for prescribing opioids. This algorithm should also include non-opioid options for patients who have less pain. Finally, focus on a multi-modal approach to pain. This approach should include other pharmacologic options for pain control such as local anesthetics and topical agents, NSAIDS when appropriate, acetaminophen, SNRIs (serotonin and norepinephrine reuptake inhibitors), and gabapentin. More importantly, it should also include non-pharmacologic modalities such as heat and ice, TENS units, distraction techniques, counseling, and education. The more we talk to our patients about the adverse effects of opioids, the more willing they may be to try alternative therapies. Perhaps if we are lucky, we can even start increasing our numbers of patients who can have their post-surgical pain managed without any opioids at all. It’s certainly a goal I’ll be shooting for.