Battling the Opioid Crisis in America

The statistics speak for themselves: Sales of precription opioid medications quadrupled from 1999 to 2010, and opioid-related deaths more than tripled from 1999 to 2012, according to the National Center for Health Statistics at the Centers for Disease Control and Prevention.

One question that has repeatedly been asked is, “How did this happen?”

“Doctors made it too easy to use opioids for pain. In 2012, at the height of the epidemic, 259 million opioid prescriptions were written—that’s a bottle of pills for almost every adult in the U.S.,” says Neel Mehta, MD, director of pain management at Weill Cornell Medicine.

Dr. Mehta also points out that opioid prescriptions were sometimes given because doctors have inadequate time to spend with patients with complex medical issues. For example, for a primary care physician who sees a patient who takes several medications for blood pressure, cholesterol, and diabetes, it’s very difficult to address any of his or her conditions in depth during a typical office visit, and some physicians prescribed opioid medications too quickly.

A Vicious Cycle for Patients

Although a large percentage of the opioid crisis is due to recreational use of illegal drugs, some patients who were prescribed opioids by their doctors have also gotten trapped in a vicious cycle of tolerance and/or dependence that is common with opioids.

“The opioid itself is not always the issue; it’s what happens when the patient has become dependent on the drug but cannot get another prescription,” explains Dr. Mehta. “For example, oxycodone (OxyContin®) was designed to be taken twice a day, but as patients developed a tolerance to the drug, they needed to take more to get the same effect, so they began taking it three or four times a day; then, they would run out of medication before they could get their prescription refilled.” This led to patients seeking out additional medication, either by “doctor shopping” to get prescriptions—or, sometimes, turning to the street.

For some patients who had developed a physical dependence on opioids, the medication was needed not only to relieve pain, but also to stave off withdrawal symptoms, which include diarrhea, vomiting, insomnia, restlessness, irritability, muscle and bone pain, and cold flashes.

How Recreational Use Turns Deadly

Of course, patients weren’t (and aren’t) the only ones using opiods; OxyContin® and other opioids became popular because of the euphoria they produced, and recreational use and abuse of the drugs became increasingly common.

Dr. Mehta says that the statistics tell part of the story: An increased number of opioid prescriptions was linked with an increased number of overdoses and deaths, but, once the number of prescriptions began decreasing, the death toll remained high. Selling opioids was big business, and drug cartels were providing the U.S. with plenty of opioid drugs for street use.

Drugs that contain opioids can be life-threatening because of the depressant effect they have on the respiratory system, which controls breathing rate. If your breathing rate becomes too slow, you lose consciousness, and, if you don’t receive immediate treatment, you can die. Another risk associated with street drugs is the uncertainty of what drugs and what dosages the user is actually getting. The rising overdose and death rates reflected the increasingly common practice of cutting heroin with fentanyl, an opioid that is estimated to be 50 times more potent than heroin. Fentanyl is very quick-acting, and it doesn’t discriminate; it can kill a long-time heroin addict as fast as a first-time user.

Changes to Medical Opioid Use

In the wake of the mounting body count attributed to opioid abuse, the Centers for Disease Control and Prevention published a guideline for prescribing opioids for chronic pain that addresses when to initiate or continue prescribing opioids, selection, dosage, duration, and discontinuation of opioids, and evaluating and addressing the risks of opioid use.

“Many states have adopted ‘acute pain laws’ that limit the number of pills that can be prescribed when it is the patient’s first opioid prescription. For example, for post-surgical pain, you may get enough opioids to last for five days,” explains Dr. Mehta.

States also have prescription drug monitoring programs that allow doctors and pharmacists to check an electronic database to find out if the patient has already received an opioid prescription in the state; in some states, using the database is mandatory, but in some, it is voluntary.

“All states have a database. The next step is for the databases to be connected nationally,” notes Dr. Mehta.

Other laws require dose restrictions or caps on the length of time (for example, 30 or 90 days) an opioid can be taken by a patient.

“In addition, certain insurance companies have created restrictions on types, doses (number of milligrams), or number of pills that they will allow a physician to prescribe. Some companies will not cover certain opioids, such as oxycodone, anymore,” says Dr. Mehta.

Making Opioids Safer

Some opioid medications are now formulated with safety measures designed to discourage recreational use; these are called abuse deterrent opioids, or ADOs. For example, Xtampza ER® is an extended-release form of oxycodone that is an ADO; if it is crushed and snorted or injected, it will only release a certain amount of the dose, so the drug will not produce the “high” the user is seeking.

ADOs may contain a substance designed to reduce or eliminate the euphoria associated with opioid abuse or a substance that produces an unpleasant effect if the drug is snorted.

However, abuse deterrent opioids are not without risk; they can still be abused, for example, by taking more than the prescribed dosage, or by combining them with alcohol and/or other drugs.

“An ADO is like a seat belt,” explains Dr. Mehta. “It can’t prevent an accident, but it makes it less likely that you will be injured if you do have one.”

And, there is a Schedule IV opioid drug with a much safer profile than oxycodone and other high-risk drugs: Tramadol (Ultram®) is being prescribed for many patients who were previously on stronger opioids. However, tramadol may be less effective, so they are often supplemented with a variety of non-opioid medications to try to achieve the same degree of relief. However. Dr. Mehta emphasizes that there are many non-drug treatment options that can help relieve pain (see the next section on pain management).

Dr. Mehta also notes that there are pain-relieving drugs being studied in current clinical trials, so it’s likely that some new medications with better safety profiles will be available in the future.

Pain Management

Dr. Mehta says that, since primary care physicians have drastically decreased opioid prescriptions, more patients are seeking care from pain management specialists. Pain management doctors have a thorough understanding of complex pain mechanisms, as well as the causes of pain and the treatment methods that are most effective.

“We are realizing that many physicians are fixated on using medications to treat two types of pain: joint pain caused by arthritis and back pain caused by stenosis and/or bulging discs,” says Dr. Mehta. “However, when a more thorough examination is conducted, we often find that the patient’s pain is related to another cause that can frequently be treated without medication. For example, many patients who are obese and/or sedentary have poor physical conditioning, so they are developing back pain that initially looks like arthritis. Upon further evaluation, we often find that it is muscle-related or myofascial pain, and we are able to provide a specific treatment regimen that helps ease the pain without high-risk medications.”

Depending on the diagnosis, patients may receive one or more of a wide range of treatment modalities.

“At the Weill Cornell Pain Management practice, our team includes acupuncture physicians, a spine surgeon, a neurologist, physical therapists, nutritionists, massage therapists, and psychologists who are trained in cognitive behavioral therapy,” says Dr. Mehta.

“One option for some patients with back and/or leg pain is the implantation of a pacemaker-like device that interrupts pain signals. These devices can be given in a trial for seven days; then, if it works, it can be installed permanently,” explains Dr. Mehta.

If you or a loved one suffer from chronic pain, there is hope: Dr. Mehta’s message is that there are numerous treatment options with good safety profiles that can effectively reduce your pain without the need for high-risk opioid medications.

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