Alex Cahana, MD | Disclosures
The Current State of the Opioid Abuse Epidemic
Two Princeton economists startled Americans recently when they reported that between 1999 and 2013, white middle-aged men and women in the United States, especially those with a high school education, were dying at an increasing rate from prescription and illegal drug overdose, alcohol and liver-related disease, and suicide.[1] Such results are not news to those engaged in day-to-day patient care; to those patients who continue to endure debilitating pain and chronic disease; or to those who have buried a loved one from a drug or alcohol overdose. Fortunately, there is the impression that finally the government and media are paying attention to this national epidemic.[2]
Presidential candidates are sharing personal stories of pain and loss and thus diminishing the stigma associated with pain, depression, posttraumatic stress, and addiction. The President's first mention of healthcare in his final State of the Union Address was about the crushing problem of drug abuse. In February 2016, Obama announced his plans to invest over $1.1 billion in the next 2 years to expand access to treatment for prescription drug abuse and heroin use, improve access to the overdose-reversal drug naloxone for first responders, and support targeted enforcement activities.[3]
The Princeton study also forces us to recognize that drug abuse is not a malady afflicting only poor, minority, inner-city communities but rather is an across-the-country phenomenon, affecting rural white adults in particular.[1] Of note, this mortality trend countering the declining death rates from other chronic diseases demonstrates that the undertreatment of pain among minorities has inadvertently "protected" them from overdose, thus reducing a decades-long death rate gap between white and nonwhite patients. These realizations are driving bipartisan support in Washington that is reflected in the Comprehensive Addiction and Recovery Act (CARA), intended to revise punitive drug policies, promote best medical practices, and strengthen data sharing among states' prescription drug monitoring programs.[4]
But are these laudable and necessary efforts the right way to go? Will increased access to care for those already harmed by addiction, addressing the enduring shortfalls in prescriber education, and research into alternative abuse-deterrent medications actually reverse this deadly epidemic?
The short answer is maybe but probably not without more initiative. Why so?
A Social Problem, Not Just a Medical Issue
First, researchers are struggling to understand why white individuals, in particular, are doing so poorly with drug abuse. Although there are no definite answers, many speculate that this cohort of patients suffers, in addition to social and economic isolation, from acute job loss. It is known that poverty, stress, and lack of social support are independent risk factors for opioid abuse. Similarly, job loss per se has been found to increase the risk for cardiovascular disease (CVD) and death.[5] Of note, recession alone does not increase CVD mortality; however, when recession is associated with job loss, heart attacks, strokes, and deaths rise. This suggests that increases in stress, despair, and possibly time spent engaging in related unhealthy behaviors often seen with financial insecurity (eg, physical inactivity, smoking, drinking, and drug abuse) may be culprits.
Second, and even more surprising, is that although awareness of the harms of opioid abuse is rising, the overwhelming majority of patients who survived an overdose continue to be prescribed high-dose opioids, often by the same prescriber.[6] It is easy to attribute these results to poor care, bad decisions, or sloppy prescribing, but it might be possible that many of the prescribers simply do not know that their patients are overdosing. Given the fact that there are no widespread systems in place to notify prescribers when overdoses occur, it is highly unlikely that prescribers will suddenly increase the level of medical supervision and care for these patients.
Third, the notion that there is a small group of prolific prescribers who are driving the opioid overdose epidemic is not accurate. The bulk of prescriptions are written by general practitioners trying to help patients with a broad array of health conditions. In fact, the distribution patterns of prescribing opioids among Medicare and Medicaid patients are no different from other drugs given for chronic diseases, where 10% of all drug prescribers account for 60% of all drug prescriptions.[7] These statistics would suggest that focusing on law enforcement, albeit merited, does not warrant significant additional resources to address improper prescribing at large.
Fourth, and most disappointing, is that despite a plethora of local, regional, state, and federal efforts to curb the overdose epidemic, things are actually getting worse. More people died from prescription and illicit drug overdoses over the past year than during any previous year on record.[8] Clearly, there is a need to do a better job in prescribing and intervening before prescription drug misuse or other substance use progresses to addiction. But are these responses a big enough step in the right direction?
Underassessment: The Overlooked Problem
The 18th century French philosopher Voltaire had many amusing quotes about medicine, such as: "common sense is not so common" and "the Art of Medicine consists of amusing the patient, while nature cures the disease." However, there is one quote in particular that is worth mentioning that might provide an overlooked solution for the overdose epidemic. Voltaire said (most probably after a dissatisfying encounter with his physician): "Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings [of whom] they know nothing."[9] This statement is still relevant for current medical practice 250 years later, but is it still accurate?
Clearly the understanding of diseases and pharmacology have infinitely increased since Voltaire's era, a time when the concepts of infections and antibiotics were unimaginable, let alone unknown. Obviously we know much more about how to prescribe medicines and how to cure diseases, but what about knowing our patients? How well do healthcare providers know their patients nowadays; and how does this intimate, context-sensitive, and unbiased knowledge contribute to the decision to prescribe (or not) drugs? When was the last time a healthcare professional used an online multidimensional, patient-reported outcome tool during a routine office visit incorporating data on sleep, movement, and diet based on a wearable FitBit-like device? When was the last time a prescriber was able to show a patient a longitudinal treatment outcome on a dashboard in real time to justify continuing or stopping treatment?
If your answer is never, you probably understand that the problem of medicine in general, and pain medicine in particular, is not the over- or underprescription of opioids, or over- or undertreatment of anything, but rather a fundamental underassessment of complex physical conditions and nuanced life narratives.
So yes, $1 billion funding of appropriate, cost-effective treatments can be expected to help with the current epidemic, but in order to reduce and not just halt rising death rates, prescribers really need to get to know their patients, like Voltaire said. Beyond human contact, professionals need to start quantifying human social traits (ie, phenotypes) at every clinical encounter in addition to their routine use of lab tests and imaging. Insurance companies need to pay for this, so that lack of time will not be an excuse for not measuring behavior, and patients need to have this actionable information (ie, health data) available. Not measuring pain interference, mood, diet, activity, exercise, and sleep limits the understanding of the effects of any therapy and makes prescribers incapable of guiding patients and their families to cope with, and remove, the obstacles that deny them the health and wellbeing they seek.[10]
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