The opioid epidemic combined with the medical community’s inclination to prescribe drugs for pain management has created a perfect storm.
The crisis has heightened the debate over the best way to treat people addicted to prescription drugs with many professionals agreeing that going “cold turkey” is not a viable solution.
The dilemma comes as the Centers for Disease Control and Prevention (CDC) releases its most on the state of the opioid epidemic.
The agency reports that fatal drug overdoses have more than doubled since 1999. In 2015, 60 percent of all drug overdoses were from opioids, ABC News reports.
The problem has become so widespread the past few years, that it’s no longer a fringe topic. It was even intertwined in the presidential election last fall, with several journalists addressing the fact that areas ravaged by the crisis tended to be strongholds for President Donald Trump. They dubbed them the “Oxy electorate.”
It was hardly the only time the epidemic showed its face in politics.
White House press secretary, Sean Spicer, offered a commentary last month on the role of marijuana in fostering the problem.
Last week, Maryland’s Republican Governor, Larry Hogan, declared a state of emergency in response to the opioid crisis. The state is pledging an additional $50 million in an “all-hands-on-deck approach” that will include enforcement, prevention, and treatment services.
No easy answers
A recent study out of Johns Hopkins University concludes that part of the problem is that those who are dealing with opioid addiction have a high likelihood of being prescribed more narcotic drugs after addiction treatment.
Researchers looked at a cohort of 50 million people between 2006 and 2013 being prescribed buprenorphine, often referred to by its trade name Suboxone. The drug is widely used to treat opioid addiction by helping wean people with opioid addictions off of other drugs as well as softening the symptoms of withdrawal.
However, the crux of the study is that, “Approximately two-fifths (43 percent) of buprenorphine recipients filled an opioid prescription during the treatment episode and two-thirds (67 percent) filled an opioid prescription following treatment.”
“The vast majority of patients that run into problems with opioids are using them exactly as prescribed, or at least are receiving these opioids from licensed prescribers,” said Dr. Caleb Alexander, the study’s co-author, and an associate professor of epidemiology and medicine at Johns Hopkins Bloomberg School of Public Health.
Alexander points to the very nature of our healthcare system as part of the culprit.
“We live in a very fragmented healthcare system,” he told Healthline, “and all too often the left hand may not know what the right hand is doing. This is particularly worrisome when it comes to the use of a medicine as potentially dangerous as a prescription opioid.”
What this means in practical terms is that communication from one of a patient’s doctors to another isn’t necessarily all that great. If your dentist prescribes you something, your general practitioner likely won’t be aware of it (and vice versa) unless you bring it up.
This situation gets even more complex when dealing with substances such as buprenorphine and methadone because these require special licensing for distribution. It’s unlikely you can see your regular doctor and walk out with a prescription for them. Instead, opioid abusers must often travel to specialized clinics where they can obtain tightly controlled doses.
“For many patients who are being treated for opiate addiction, this component of their care is sort of walled off or pursued separately from their routine primary care,” said Alexander.
While the Obama administration did make some headway in making buprenorphine more accessible by easing restrictions on doctors’ ability to dispense it, the substance is still highly controlled.
Trying to slow prescriptions
What the current research suggests is that without more oversight, these drugs’ efficacy is questionable.
Researchers note that the median length of a buprenorphine treatment was only 55 days, meaning the average user stuck with it for less than two months.
Within the current system, a patient dealing with opioid addiction could be prescribed buprenorphine and then several weeks or months into the treatment, the patient breaks their leg. In the emergency room, they are subsequently prescribed oxycodone for the pain.
But there are some stopgaps in place.
The rise of Prescription Drug Monitoring Programs (PDMPs) — statewide databases that allow physicians and pharmacies to see drug prescription records — are essential in helping to slow overprescription.
“In terms of trying to get some sort of a flag going, pharmacists, when they see that people are on buprenorphine, have the ability to not fill an opiate prescription and in some cases, even a benzodiazepine prescription without notifying the prescribing physician,” Dr. Louis E. Baxter Sr., president of the Professional Assistance Program of New Jersey, told Healthline.
But these systems are still limited and almost always restricted by state.
Baxter notes that being in a tristate area, the medical community is attempting to coordinate interstate databases.
“There are earnest efforts being taken to sort of make these more of a regional and ultimately a national database,” he said.
Dealing with pain
There is still a much larger issue at stake, of which PDMPs are only part of the solution.
The most crucial part of the opioid crisis narrative that research points to is that patients dealing with opioid dependence may also be dealing with legitimate pain issues. So, being prescribed buprenorphine and an additional opiate may in fact be “justified clinically.”
However, CDC Director, Dr. Tom Frieden, has gone on record saying, “Plainly stated, the risks of opioids are addiction and death, and the benefits for chronic pain are often transient and generally unproven.”
“Some have characterized what I would argue is a false conflict between, on the one hand, quality of care for those in pain, and on the other, reducing our overreliance on opioids,” said Alexander. “These two are not fundamentally in conflict.”
“For far too long, we’ve overrelied on prescription opioids at great cost to millions of Americans,” he added.
Baxter agrees that pain management must be scrutinized, particularly for those who are not dealing with chronic issues. Sprains, breaks, and other short-term injuries may not need opioids at all.
“Most acute pain only lasts four to five days,” he said, pointing to more mundane, nonsteroidal anti-inflammatory drugs as effective pain relievers.
“People get good pain management with those non-opiate medications,” Baxter said.
Additionally, there are plenty of other pain solutions available, including massage therapy and physical therapy.
Drugs alone aren’t the answer
Both Alexander and Baxter disagree with the notion that a drug like buprenorphine is effective on its own.
“Anybody that is only being prescribed buprenorphine and is not having any counselling, they are all doomed, in my view, to return to use and abuse of opiates,” says Baxter.
“What should be done,” he continues, “is that when patients with opiate abuse issues present for treatment, they need to be evaluated to see if they have any significant pain issues, any chronic pain issues, and they also need to be evaluated to see if they have psychiatric issues.”
His recommendation for a more holistic approach to the problem, which includes drugs such as Suboxone, also incorporates counseling and rehabilitation. This “full treatment” approach, he says, has a 70 percent success rate.
“In a situation in which individuals only use the buprenorphine and none of [the other treatments], that success rate is down there less than 20 percent,” he added.
Baxter and Alexander both caution against the notion of going “cold turkey” because it is dangerous and ineffective.
“In the past, it was thought that if you let somebody suffer through withdrawal that will help them never to use again because it’s such a terrible experience, but that has been shown to pretty much be folklore, and it’s not true,” said Baxter.
Instead, by including additional therapy and oversight for people dealing with pain and opioid addiction, there are viable alternatives.
Baxter and Alexander are both optimistic about the ways that our healthcare system is changing to deal with the opioid crisis and its intersection with pain management.
Alexander says that buprenorphine is “far from a panacea.” Instead, patients need to be engaged.
Frieden’s answer is even more straightforward.
“The prescription overdose epidemic is doctor-driven. It can be reversed, in part, by doctors’ actions,” he said.