Mohammed Zaahid Sheriff
Public Health
March 28, 2017
Prescription Drug Overdose
A look into the opioid crisis
In the past few decades medicine has developed in leaps and bounds. There are numerous diseases that have been described which were a mystery before. At the same time, doctors have become better equipped to deal with disease, armed with the tools provided by the pharmaceutical industries. It is not uncommon to find designer drugs used to treat diseases, for example antibodies specifically designed to fight a tumor which is expressing a certain protein. However, with the advent of new drugs the potential for abuse has increased too. While a lot of emphasis has been placed on street drugs such as heroin, less emphasis has been placed on drugs prescribed by the physicians themselves. However prescription drugs do represent an important cause of morbidity and mortality. In this paper I aim to highlight some of the aspects of opioid use, and to discuss the significant burden caused by these drugs.
It is important to identify the extent of the problem in our analysis of it. According to one paper, drug overdose deaths represent the leading cause of injury related deaths in the United States of America (1). A notable amount of these deaths were due to prescription drugs, of which opioids are the major concern. In fact, since 1999, the number of overdoses related to opioids (including both the prescription opioids and heroin) has more than quadrupled (2). It is apparent that the driving factor behind this increase is not a significant increase in street drug abuse, but rather an increase in prescription opioid use. In fact, during the same time period, the amount of prescription opioids sold has almost quadrupled in the United States. Surprisingly, the amount of pain reported by the citizens of the United States has not changed significantly during this time (3). This suggests it is a change in prescription practices that is behind the increase in use of these drugs. Death from prescription opioids including oxycodone, methadone, and hydrocodone has increased four fold since 1999 in the United States (2).
Of the prescription drugs that cause drug overdose deaths, the ones that are most concerning are those in the opioid class of medication. Opiates are alkaloids that are found naturally in the opium poppy plants. This class of drugs is one of the oldest known drugs to man. Indeed, the recreation use as well as medical use of these drugs predates modern civilization. These plants contain the compound morphine, codeine and thebaine. Since they have been discovered, many semisynthetic opioids have been derived from these compounds, and completely synthetic compounds that act on the same receptors have been discovered. The particulate receptors in question are the mu, kappa, and delta opioid receptors. Binding results in the activation of these receptors and brings about its effects. In addition to the treatment of acute, chronic, and cancer related pain, opioids are also used to treat cough, diarrhea and constipation, and shortness of breath. Unfortunately, the use of these drugs can lead to tolerance developing, as well as physical dependance and addiction. The most concerning side effect of large quantities of opioids is respiratory depression, which can lead to death. The danger not withstanding, many people do misuse these drugs, as a result of addiction and physical dependance.
Unfortunately while opioids are vital in the treatment of pain, they have a very high potential for abuse, which unsurprisingly leads to more overdose deaths. Due to this high potential of abuse exposure to these drugs should be limited. However, current data has shown that 1 out of 5 patients who have a non cancer related pain or a pain related diagnosis are prescribed opioids (5). In the past few decades, pain has been emphasized as an additional vital sign, so that physicians learn to recognize and treat pain. However in doing so, too much emphasis has been placed on “curing” the pain, leading to unsafe prescribing practices. A change in physician behavior in an attempt to solve this problem is no doubt needed.
In 2016, the CDC has taken a step in the right direction, releasing a new guideline for the prescription of opioids in chronic pain. This guideline supported the use of non opioid medication as a routine in the treatment of chronic pain. Options for non opioid medication include Paracetamol, ibuprofen, physical therapy, antidepressants, antiepileptics, and therapy such as cognitive behavioral therapy. If opioids are needed, they are to be used in combination with other medication which will provide a great benefit than the use of opioids alone. In addition, when opioids are to be used, they are to be started at low doses (the lowest effective dose) and started as immediate release rather than long lasting (minimizing exposure and making sure only the quantity needed to treat pain is prescribed). Finally, close follow up is suggested to ensure that the benefits to the patient outweigh the harm. If they do not, other medication should be used and the opioid should be tapered and dosage reduced or discontinued as needed.
Another manner through which the misuse of opioids can be controlled is through prescription drug monitoring programs. A prescription drug monitoring program is typically an database which contains details of all the prescriptions prescribed to an individual. With an easily available record of previous prescriptions it will become very easy to identify potential misuse of drugs (i.e. too much quantity over that which is required to treat pain.) With the patient’s history readily available the providers will be able to get the help a potential abuser will require, and it will prevent the unwitting support of a drug abuse problem by a physician. This will lead to an improvement in safety for patients as a whole. The patients in need of treatment for an opioids use disorder can be identified and medication such as naloxone can be prescribed as required.
Certain features of a database makes the concept of Prescription Drug Monitoring Programs a promising concept. If established at a state level they can be universal and include all the hospitals potential drug abusers visit to access drugs. This ensures that they do not receive medications at multiple outlets. In addition as an electronic database, the records can be updated in real time and thus holds a significant advantage over paper based records. Furthermore, the database can be easily studied to identify the epidemiology of the disease. This can help states identify a possible intervention to help in the epidemic. Of course, if the PRDRP is an electronic database, it is very easy to access and can be incorporated into the electronic health record of the patient, streamlining care for them.
Of course, spreading awareness about the problem in the general public is of utmost importance too. The dangers of opioid use should be well demonstrated. and the series available for patients who are addicted should be highlighted. Currently, the most well known antidote to an opioid overdose is the antagonist naloxone. In the past few years, naloxone is becoming more widespread and available, and thus it has a potential to decrease the number of overdose deaths. In fact, studies have shown that providing naloxone to laypersons is effective in reducing the number of overdose deaths (6). While this study was more focused on heroin use than prescription drugs, we can expect a similar effect to occur with prescription opioids which operate through the same mechanism as heroin. An education program at a state level can help laypersons identify the signs of addiction and overdose and how to respond to an overdose by administering naloxone. This will undoubtedly decrease the number of opioid related deaths. In fact, making naloxone kits readily available to the family of the patient receiving the medication may prove to be an intervention that will significantly reduce the number of prescription drug overdose deaths as they are the individuals most likely to have first contact with someone who has overdosed.
Of course, opioid overdose is not the only concern from a public health perspective. Other drugs, such as stimulants such as amphetamines used in the treatment of disorders such as ADHD also have the potential to be abused. In addition to analgesics, sedatives such as benzodiazepines and barbiturates also have an addictive potential. However, opioids as a class present a greater danger from the public health perspective and thus more effort should be directed at controlling this epidemic.
Finally, the use of prescription medication is also a factor responsible for the increase in use of street opioids such as heroin. In exposing the patients to opiates and then limiting their use, the population begins to look for other options, thus leading to a spike in street drug use. Thus, a decrease in the amount of opioids prescribe can potentially lead to decrease in street drug use and a decrease in deaths due to street opiates such as morphine.
Prescription drug overdose is thus an important public health issue and should be considered by physicians whenever such controlled medication is prescribed. Care should be taken by physicians to avoid these drugs and to use them only when there is no safer alternative.
References
1 Haegerich, T. M., Paulozzi, L. J., Manns, B. J., & Jones, C. M. (2014). What we know, and don’t know, about the impact of state policy and systems-level interventions on prescription drug overdose Drug and Alcohol Dependence, 145, 34-47. doi:10.1016/j.drugalcdep.2014.10.001 [doi]
2. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov.
3. Chang H, Daubresse M, Kruszewski S, et al. Prevalence and treatment of pain in emergency departments in the United States, 2000 – 2010. Amer J of Emergency Med 2014; 32(5): 421-31.
4 Ossiander EM. Using textual cause-of-death data to study drug poisoning Ossiander EM Am J Epidemiol. 2014 Apr 1;179(7):884-94. doi: 10.1093/aje/kwt333. Epub 2014 Feb 1112.)
5 Centers for Disease Control and Prevention. Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines — United States, 2012. MMWR 2014; 63(26):563-568.
6 Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med 2013;158:1–9.