This is the last in a series exploring the intersections between effectively caring for people living with chronic pain and the rise in unintentional poisoning deaths due to prescription painkillers. This week's story looks at the role of public health in curbing the opioid abuse and overdose problem. Read the previous stories in the series here and here. (We'll be publishing a bonus addition to the series next week — a discussion with Dr. Daniel Carr, director of the Pain Research, Education and Policy Program at Tufts University.)
by Kim Krisberg
A decade ago, only about 10 percent of the patients at Cincinnati's Center for Chemical Addictions Treatment were admitted for opioid addiction and abuse. During the treatment center's last fiscal year, that number was up to 64 percent. The center helps about 1,000 people every year on an inpatient basis.
Sandra Kuehn, the center's president and CEO, describes an addiction and abuse pattern that she says she sees all too often: A young teenager who is prescribed a pain reliever for an injury begins rummaging through mom and dad's medicine cabinet after his or her legitimate prescription runs out. When that stops working, the teen starts looking for the pills on the streets. And when teenagers and young adults in that situation start running out of money, some turn to heroin, which is typically less than half the cost of one OxyContin pill. It's a pattern that helps explain why 22- to 24-year-olds have become one of the most common age groups at the center — a demographic that would have been unusual to see at the Ohio rehab facility until about eight years ago, Kuehn told me.
"By the time they get to center, they've often been struggling (with addiction) for years," she said. "Of course, it's not the same for every single person, but it's a pretty good pattern. ...What we see are a lot of young adults who are typically from a middle-class background, whereas addiction used to be seen as happening in the back alleys. It's really grown out to be much more of a suburban problem. It's happening everywhere."
And unfortunately, opioid addiction is quite difficult to treat — Kuehn notes that there's been an inverse relationship between the number of opioid patients admitted to the center and the rate of those who successfully complete the treatment program. The opioid abuse problem in Ohio is startling, and Kuehn says she doesn't think the numbers she sees at the center have even crested.
"It's hard to know what the solution is," she said.
To be sure, curbing opioid misuse and unintentional poisoning is just as — or even more — complex than the many factors that created and fueled the problem in the first place. It's an issue that requires input, action and coordination between many different sectors and stakeholders; it requires new systems, policies, education, awareness, surveillance, funding and enforcement; and throughout it all, players must be mindful of inadvertently restricting opioid therapy access for legitimate pain patients. Such complexities are typical in the public health field, and so it's no surprise that public health practitioners have stepped to the forefront.
Such is the case in Ohio, where opioids have driven a 372 percent increase in the death rate due to unintentional drug poisonings and where an average of 67 doses of opioids were dispensed for every state resident in 2010. The problem had reached such epidemic proportions that in 2011, Gov. John Kasich established a Governor's Cabinet Opiate Action Team. Ted Wymyslo, director of the Ohio Department of Health, co-chairs the action team and brings that critical population-based perspective to the effort.
"People in Ohio are dying and we have to take this very seriously," Wymyslo told me. "We know we have a one-to-one correlation in the rise of milligrams prescribed and the death rate rise — they are perfectly matched."
Among the first orders of business for the action team was provider education. And after months of work and convening diverse stakeholders, the team released new opioid prescribing guidelines for emergency departments and urgent care centers in May 2012. Such settings are a common source of opioid prescriptions, and the nature of emergency health interactions between patients and providers can make it difficult to accurately assess a person's needs. Today, almost every major health system in Ohio has adopted the prescribing guidelines, Wymyslo said.
"They've taken it verbatim and made it policy," he told me. "It means we're on the right track."
Now, Wymsylo and his colleagues have turned their attention to opioid prescribing in non-emergency settings — a much bigger challenge, he said.
"We're taking a collaborative approach and so we're expecting a much better collective impact," Wymyslo said. "We're leaving no stone unturned."
Painkillers and public health
Ohio is hardly alone when it comes to the prescription painkiller problem. According to the Centers for Disease Control and Prevention, death rates due to drug overdoses have more than tripled since 1990, and about three out of four prescription drug overdoses are due to prescription painkillers. The agency reports that in 2010, more 12 million people reported using the drugs for recreational purposes and without a prescription.
In Florida, the rise of prescription drug abuse translated into seven related deaths every day. Prescription drugs accounted for 79 percent of drug-related deaths in the sunshine state in 2009, and the painkiller oxycodone was the top culprit. In fact, a Drug Enforcement Agency news release noted that "Florida has been viewed as the epicenter of the nation’s ‘pill mill’ epidemic."
In Sarasota County on Florida's West Coast, public health officials began noticing alarming trends in medical examiner data regarding prescription drug-related deaths in 2008. In response, "we do what we always do in public health," said Charles Henry, director of Sarasota County Health and Human Services, "we began building community capacity, partnering (with stakeholders) in the community, studying the problem and developing a plan of action."
Henry and his colleagues brought the worrisome data to the larger community, pointedly reaching out to local health providers to collaborate on the problem. The larger community work, which included a number of public forums, eventually culminated in adoption of a local ordinance in 2011 that, among other measures, zones the location of pain management clinics, enables data sharing and requires pain management providers to use the state-run Prescription Drug Monitoring Program (PDMP), which lets a physician view a patient's prescription history and helps prevent doctor shopping and drug diversion.
Today, Henry reports that Sarasota County is one of the PDMP's highest users — more than 400 providers, from physicians to dentists to pharmacists, are using the system. Anecdotally, he tells me that many local doctors didn't think their patients fit the drug abuse profile; but as they began using the state monitoring system, they found they did, indeed, have patients struggling with addiction and could then refer them to appropriate treatment. Rebecca Poston, program manager for Florida's PDMP, said that 53 million records have been reported or uploaded to the database, noting that there's been a 35 percent reduction statewide in the number of residents visiting five or more prescribing providers or pharmacies within a 90-day period.
"Hearing these stories tells us that what we're doing is making a difference," Henry said. "The most critical part of this was working with physicians from the beginning. If you don't have their buy-in, it won't be successful."
He said while the health department is "anxiously" awaiting 2011 data to see just how much of a difference the policy and systematic changes have made, he reported that raw data from the local medical examiner's office hints at a positive turnaround: From 2010 to 2011, there's been a 9.2 percent decrease in accidental deaths involving prescription drugs.
Prescription drug take-back efforts have also been key in Sarasota County — a strategy that helps curb drug diversion. According to Wayne Applebee, criminal justice policy coordinator with Sarasota County Health and Human Services, establishing 24/7 dropboxes at local law enforcement agencies more than quadrupled the pounds of unused prescription drugs residents dropped off between 2010 and 2011.
"From what we're hearing anecdotally, it feels like we're going in the right direction," Applebee said.
In Utah, where overdose deaths due to prescription painkillers have increased by more than 400 percent, a successful education campaign directed at the both the public and providers and known as Use Only As Directed contributed to a 28 percent drop in opioid-related deaths. Robert Rolfs, deputy director of the Utah Department of Health, said the agency modeled the campaign's strategy similar to those addressing antibiotic overuse. In other words, "you have to work on both sides of the equation — patients and doctors."
"If you have a set of tools for how to interact with patients, then physicians can turn an adversarial relationship into a more constructive one," Rolfs told me. "You can't always give patients what they want, but you can help them."
Ongoing funding is also an important element for a successful effort. After Utah’s campaign suffered a funding cut in 2010, the opioid-related death rate started to tick back up. In Florida, state statute prohibits the state health department from using its own funds or any funds from drug manufacturers to support its Prescription Drug Monitoring Program; funds come instead from eligible donations and grants. Unfortunately, state news outlets report that funding is starting to dry up, threatening a critical tool in balancing patient needs and risk reduction.
In an effort to adapt to funding cuts in Utah, Rolfs said law enforcement has taken the lead on the Use Only As Directed campaign. He said the health department is still able to work on the problem even without extra resources, but its role as convener is much smaller. In confronting opioid abuse, he noted that public health not only plays an important role in education, but is particularly apt at convening the diverse stakeholders needed to ensure success. He said that while Utah is taking steps in the right direction, "I wouldn't want to pretend like we've solved (this problem)."
"This is all tied into the fact that we aren't doing as good a job as we can at managing pain and we have people who are ending up with complications of substance abuse and drug addiction and we have providers who are challenged in trying to do what they're supposed to do in taking care of patients," Rolfs said. "Pain is one of the most important health problems we all face in life...We have to continue to balance treating people with pain and getting a handle on the unintended consequences of the greater use of these medications."
To learn more about opioid misuse from a public health perspective as well as related recommendations, visit www.cdc.gov/homeandrecreationalsafety/rxbrief.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for the last decade.
I would argue that a lot of the opioid dependence occurs among people who are not pharmacologically aware, and that educating patients will reduce dependence drastically.
As far as I can tell from anecdotal experience and accounts, pain patients are given no instructions beyond "take as directed and don't drive." This is a woefully inadequate state of affairs. Pain patients who are receiving opioids should be given sufficient medical counseling that they fully understand the risks of these medications, potential drug interactions, and protocols for safe pain management. They should be given this counseling before they take their first dose. And acute patients who, to put this bluntly, lack the intelligence (regardless of education) to understand what they're being told, should probably be treated on an inpatient basis.
Perhaps the best time for the first lesson is when someone is still in serious pain. "You want the pain to stop. There are many medications that can stop pain. When pain is severe, it takes strong medicines to stop it, such as this bottle of narcotic pills. But if you misuse these pills, eventually they will stop working, and beyond that, even a lethal dose won't work. At that point, even if you're in howling pain, nothing will stop the pain."
Lesson 2: Use the narcotics sparingly, and always seek to transition to OTC pain meds at the first opportunity. Keep testing yourself: when the dose starts to wear off and the pain starts to come back, take an OTC med and see if that reduces the pain enough. If not, then take one of these prescription pills. If you're aware and keep testing like that, pretty quickly you'll find a point at which OTC pain meds are sufficient and you can stop taking these narcotics.
In this context be sure to emphasize the risks of acetominophen and alcohol: if taking Tylenol, no drinking, unless you've got enough money saved up to pay for a new liver.
For chronic pain patients the goal should be to move them to a mix of a minimal quantity of narcotics plus as much OTC medication as needed. Properly educated they'll be internally motivated to do this in order to preserve as many pain relieving options as possible.
There are some patients for whom it will be necessary to keep them on opioids for the rest of their lives or until entirely new treatments are available. These include some who lack the intelligence or other capability to manage their own medications safely. Each of these cases needs to be evaluated individually, but for ethical reasons it's preferable to err on the side of providing treatment rather than withholding treatment. A society with a small percentage of opioid addicts who are properly managed, is far preferable to a society where innocent chronic pain patients face a lifetime of extreme suffering.
I also tend to believe that legalizing recreational marijuana will reduce opioid abuse, by providing a safer substitute for self-medicating the psychological needs that make opioids attractive to certain individuals. This in addition to the fact that cannabis itself has pain-relieving properties that will be useful for some patients as part of a general pain management strategy.
Lastly, we need more research into the neurophysiology of "addictive personalities" and their opposites. I'm one of the opposites, for whom opioids hold no personal attraction, in part because I'm pharmacologically aware and in part because I'm extremely sensitive to medication and also experience pain relief on placebo. The only generalization I can make from my experience is that perhaps there is some value in training people to become placebo reactors, or in teaching people to value being able to think clearly. None the less there is probably some underlying neurochemical factor in common among people who can take prescription pain meds carefully and safely, and I can assure you it is not a lack of sensitivity to pain.
I have overdosed on opiates in Ohio. Lucky to be alive.