U.S. Opioid Abuse: Teaching Is Fundamental

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Commentary — September 2016 

Tex Med. 2016;112(9):11-12.

By Emilie Y. Prot, DO

Abuse of prescription pain medications has become a national epidemic behind the top three most commonly abused substances ― alcohol, tobacco, and marijuana ― according to the U.S. Department of Health and Human Services and the U.S. Centers for Disease Control and Prevention (CDC). Patients are asking: "If a physician prescribes a medication, shouldn't it be safe?" 

The dangers of misusing prescription pain medications persist. Pain medications are not only highly addictive but also cause many overdose deaths. According to CDC, nearly 15,000 people die every year of overdoses involving prescription painkillers, especially Vicodin and OxyContin. How and when did our society become a "pill-popping" nation? 

President Barack Obama's 2017 budget includes $1.1 billion to combat the country's opioid epidemic. Funds would be allocated to treatment centers, physicians and health care providers specialized in substance treatment, and research for treatment program evaluation. In October 2015, President Obama issued a memorandum on prescriber training and opioid use disorder treatment to train health care professionals on appropriate opioid prescribing. Additionally, CDC released 2016 opioid prescribing guidelines to help doctors provide safer and more effective care, while reducing the patient's risk of addiction and overdose. The U.S. Food and Drug Administration has developed the Opioids Action Plan, which strengthens the review and approval of opioids and expands access to abuse-deterrent formulations and label changes.

The undesirable effects of tolerance and abuse followed the introduction of opioids in the 16th century. In the United States, 24.6 million people aged 12 or older (9.4 percent of the population) live with substance dependence or abuse, according to the American College of Preventive Medicine. Of these, 1.9 million Americans live with prescription opioid abuse or dependence. Health care professionals prescribing pain medications must balance effectively and aggressively treating pain with the risk of misuse and abuse. Overtreatment of pain has harmed the population, with increased hospitalization for overdoses, polypharmacy (the use of four or more medications by a patient who is generally older than 65) in nursing homes, and increased deaths.

On the other hand, the Universal Declaration of Human Rights states every human being has a right to "a standard of living adequate for health and well-being." Treatment for pain and suffering should not be reserved for the most privileged, but should be a right of access to all. 

By not treating pain adequately, patients suffer not only from physiological and psychological effects but also from socioeconomic consequences. The Institute of Medicine estimates the total loss of productivity secondary to pain at around $316.5 billion for 2010 in the United States. However, the biggest loss was not due to missed work (about $12 billion) but rather due to "reduced effectiveness" in the workplace (about $61 billion), according to a 2015 article in the Journal of the American Medical Association. Treating pain inadequately is not only medical malpractice but also poses a great economic burden to our society.

Successful, brief interventions, such as motivational interviewing, can reduce prescription drug misuse and abuse. Additionally, policies regulating disposal of unused prescription medications can further limit distribution. More research should be done on identifying and better understanding the behaviors of specific subgroups of pain medication users. 

A New England Journal of Medicine study published in 2016 found no significant association between opioid outcomes and state legal restrictions. Texas enacted its prescribing monitoring system in 1997, and according to Health Affairs had death rates of fewer than three per 100,000 population. A 2014 study published in the journal Injury Epidemiology estimated drug overdose mortality increased during 2016–17 at 16.1 deaths per 100,000 population with a decline later. Although current literature disagrees on the outcomes of prescription drug monitoring programs on overdose deaths across all states, Texas needs to recognize opioids as a public health issue and keep its monitoring and surveillance systems in place.

As a physician resident working alongside attending physicians and public health leaders, I observed different philosophies with pain management. Although pain is subjective and should be treated individually, with this urgent epidemic in mind, guidelines must be respected. There should be a concerted effort in educating the public and medical professionals, as well as developing policies. 

Training in opioid prescription and treatment should begin early and continue. Our medical graduates should be trained to deliver the best care to our patients and address this taboo without any reservations. 

Emilie Y. Prot, DO, is a resident in the Texas Department of State Health Services Department of Preventive Medicine and a member of the Texas Medical Association Council on Health Promotion. Emilie Becker, MD, Medicaid/Children's Health Insurance Program mental health director at the Texas Health and Human Services Commission, contributed to this article.

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May 03, 2018

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