Like many of you reading this, I have been surprised by all the news headlines that have come out over the last few months about opioid addiction. For far too long it seemed as if the government and news media were ignoring the problem. Finally, on August 10th, the President declared a national health emergency over the opioid crisis.
The problem of opioid (prescribed and non-prescribed) addiction and specifically deaths from opioid overdose have worsened, especially over the last 15 years, to the point that in 2015, 33,091 Americans died of opioid overdose; That is 91 per day,15% more than the record set the year before. Deaths from drug overdoses, most of which are opioid overdoses, are higher than the death rates during any prior US drug epidemic. Preliminary data for 2016 suggests that the epidemic has gotten worse since 2015.
Opioids include heroin, fentanyl, oxycodone (OxyContin, Roxicodone, “oxys”), oxymorphone (Opana), hydromorphone (Diluadid), hydrocodone (Vicodin, Norco). Opioids have a legitimate medical role in treating some extreme acute pain, or pain in cancer patients, but starting in the early ’90’s doctors began to prescribe them much more often. Prior to this, there was much reluctance to use these drugs which were thought to be, and are now known to be, very addictive. Then, in the early 90’s, the medical community began to push the idea that doctors should inquire about pain on every visit and treat it sometimes with opioid medication. Biased drug company studies were then saying opioid medications weren’t as addictive as feared. Purdue Pharma, producer of OxyContin, in 2007 paid hundreds of millions of dollars in fines for its false claims. I remember being in medical school at UCSF during this time and having a lecturer tell us that doctors needed to start taking pain more seriously, opioids were not very addictive, and that we should be prescribing them much more often to alleviate pain. So many doctors of my generation received this message, and had a desire to “satisfy the customer”, that the number of prescribed opioids increased dramatically over the 90’s and 2000’s. Whereas before, a patient with an injury would usually receive ibuprofen, Tylenol, or naproxen and physical therapy, in the 90’s and 2000’s they began to receive 30 days of prescribed opioids. Over the past few decades experts estimate that Americans consumed 80-90% of the global opioid supply. Now, the Center for Disease Control feels addiction to opioids can start as early as the 5th day of their use and the risk increases dramatically after the 31st day of use.
The deaths from opioid overdoses first began to rise with the increase in prescriptions, as doctors attempted to treat patients’ pain. Then some people hooked on prescription painkillers began to use heroin as they, or their sources of drugs, lost their prescriptions and the street price of prescribed opioids rose dramatically in comparison to heroin prices. More people began to die of heroin overdoses. Then more recently, heroin has become adulterated with, the 50 times stronger, fentanyl and the death rate increased further. Some states have been hit harder than others. West Virginia, New Hampshire, and Ohio have been particularly affected. Luckily, California has not been as afflicted. In some states, doctors have filled out more painkiller prescriptions than there are people.
These pills don’t just end up in the patient’s hands; they are shared among friends and family, land in the hands of teens who rummage through medicine cabinets of their parents and grandparents, and some end up being sold on the streets. Opioids are especially lethal when combined with benzodiazepine tranquilizers (Xanax, Ativan, Valium, Klonopin) or Alcohol.
As of 2015, at least 2 million Americans were estimated to have an opioid use disorder, but less than 10% of people who meet the criteria of opioid addiction get treatment. The most effective way of treating opioid addiction is called medication-assisted treatment (MAT). MAT combines counseling, or other behavioral therapies, with medications like buprenorphine, naltrexone, or methadone. Addicts treated with buprenorphine or methadone are half as likely to relapse compared to those not on MAT, are able to hold down jobs, and be parents, etc. The medications work to relieve the symptoms of opioid withdrawal and/or block the effects of opioids, while the behavioral therapy and counseling help patients improve coping skills and reduce the likelihood of relapse. Patients who use MAT have improved outcomes, less hospital stays, less criminal behavior, and lower rates of overdose death.
In some areas it can be difficult accessing MAT. For example, 53% of US counties do not have a physician with the special training and waiver required to prescribe buprenorphine. Methadone must be obtained from federally supervised clinics, where clients initially come every morning for their dose of medication. Most insurance companies have no restrictions on prescribing opioids, but MAT meds require a prior authorization and may have arbitrary dosing and duration restrictions. The federal government does not limit the number of prescriptions for opioids that a doctor can prescribe, but it does severely limit the number of prescriptions for buprenorphine that a doctor (who has gone through the additional required training) can prescribe per month. Thus, the federal and state governments have made it very easy to prescribe quantities of opioids that start and continue the addiction, but make it difficult to obtain the medications that then treat this addiction.
Nationwide, Blue Cross Blue Shield insurance did a study showing that 20% of their customers were prescribed an opioid painkiller at least once in 2015. Other studies show that prescription opioid sales increased 300% from 2001 to 2012. Claims for opioid addiction and dependence surged nearly 500% between 2010 and 2016, but many of these patients do not get MAT. The Blue Cross Blue Shield study also found that people in the areas hardest hit by the epidemic are least likely to get MAT. These findings are similar to surveys of people with Medicare, Medicaid/MediCal, or other government health insurances. Fortunately, the Obamacare Medicaid expansion resulted in a 70% increase in buprenorphine prescriptions.
The problems of opioid addiction have taken decades to develop and it will take years to resolve. There are many steps that the states, federal government, and insurance companies can take to help stem this epidemic, hopefully they will do so. As individuals, we can write our representatives encouraging them to take action on this crisis. If you, or somebody you know, has an opioid problem ask your doctor or insurance company about medically assisted treatment.
DR. LENNART MOLLER ,
M.D. , Psychiatrist