Observations of the Opioid Epidemic
Significant attention has been directed towards the opioid epidemic in the United States as it has caused considerable trauma and suffering for addicted individuals, families, and significant others. This serious public health and safety problem has also affected our criminal justice, medical, psychiatric, addiction, and social service systems as more attention and resources are need to manage the many problems caused or exacerbated by the effects of opioid misuse and addiction. We are all affected in one way or another. Stories continue to emerge regularly on TV, the Internet, and written media about the devastation caused by untreated opioid addiction.
This epidemic resulted from a substantial increase in overdose deaths due in part to the following:
- More potent forms of opioids
- More drug users transferring addiction from prescription opioids to heroin
- Increased attention to the overuse of prescription opioids for noncancer pain
- An increase in opioid addicted individuals entering rehabilitation or other addiction programs
- An increase in the use of buprenorphine to aid recovery
- More public awareness of the many problems caused or exacerbated by opioid addiction
- Increased state and federal initiatives to address this epidemic
I have read many published reports and attended numerous meetings in which the many aspects of this epidemic have been discussed, and viewed many programs on TV or the Internet. I am pleased that this serious public health problem is receiving considerable attention as more medical and behavioral health providers, community leaders, and others are finally addressing it.
Following are my observations about this epidemic and what we still need to do.
Considerable attention is directed at the opioid drug or overuse of prescribing opioids to individuals with pain that is not chronic or related to cancer. More attention should be on the human element and what causes misuse or opioid use disorders (OUDs), and how these wreak havoc on affected people, families, and society. More focus is needed on understanding risk factors and early screening of opioid and other substance use in medical settings, evaluating effects of this use, engaging and/or linking those with OUDs to treatment, and insuring more patients receive medication-assisted treatment for OUDs.
The past decade has seen a substantial increase in the prescription of opioids by physicians, especially in response to the mandate to evaluate pain as one of the vital signs. Dental and medical practices need to evaluate their prescription practices, which may lead to fewer prescriptions, fewer pills per prescription, and less potent forms of opioids prescribed. The Centers for Disease Control and Prevention (CDC) recently published guidelines for prescription practices, which can be found online. These guidelines cover dosing strategies (e.g., types of opioids, dosages, quantity to prescribe, and length of use); benefits, harms, and adverse events associated with opioid use; risk assessment and mitigation strategies; effects of using opioids for acute pain or long-term use; alternative nonopioid treatments for pain; and when to initiate, continue or discontinue opioid use. A change in medical and dental education and prescription practices is one way to reduce the number of individuals who use and/or become dependent on opioids, or relapse following a prescription for a medical problem that is not closely monitored.
There is too little attention on “other” substances or psychiatric problems among those with an OUD. Problems with alcohol, benzodiazepines, and other substances are common and deserve the focus of our education, prevention, treatment, and research initiatives. Since psychiatric comorbidity is common, the ideal approach to treatment is to provide integrated care that focuses on both types of disorders.
Substance Use Disorders
Many addiction treatment resources are now directed towards individuals with OUDs. I recently talked with two leaders of large-scale treatment systems who reported that the majority of their residential clientele are now in treatment for an OUD. We have an obligation to address the treatment and recovery needs of individuals with other substance use disorders (SUDs) and must not forget that these individuals and their families also experience many adverse effects of these disorders. Alcohol use disorders are the most common, yet fewer of these individuals are entering treatment. Additionally, the greatest annual mortality is associated with nicotine dependence (nearly 500,000 die) or alcohol problems (over 100,000 die).
Most of the treatment dollars support the acute phase of treatment such as detoxification, residential or brief outpatient rehabilitation programs. A continuum of care that provides more long-term residential (therapeutic communities and halfway houses) and outpatient continuing care is needed as well as easier and quicker access to medication-assisted treatments (MATs) like buprenorphine. Recovery check-ups and outreach to early treatment dropouts can have a positive impact on this problem.
Lack of Providers
There are not enough addiction providers to meet the demands for MATs. More licensed addiction programs, especially “drug-free” rehabilitation programs, need to be flexible and consider offering MATs to individuals receiving care for an OUD. When feasible, primary care, internal medicine, family medicine, and other medical practices should offer MATs on-site as well as insure individuals who receive these medications get linked to psychosocial programs in the community if these services cannot be provided on-site.
Hospitals and emergency rooms (ERs) do not routinely screen or assess for OUDs or other SUDs, or do not always include an identified OUD in the treatment plan. I have spoken to many physicians, nurses, social workers, and patient navigators who agree that medical providers need to gain more addiction literacy and increase their understanding of OUDs and other SUDs, acquire skills to intervene (e.g., SBIRT or screening, brief interventions or referral to specialty addiction treatment), and get rid of negative and judgmental attitudes, especially towards drug seekers. Anyone who understands addiction and how the brain can be hijacked so that “anything goes,” knows that affected individuals will do anything or go anywhere in search of opioids, including medical settings. On-site peer navigators is one excellent strategy to increase the focus on SUDs in hospitals and ERs and get those with SUDs into treatment.
Prescription drug monitoring programs (PDMPs) enable physicians, other providers, and pharmacists to get a more accurate picture of patients’ use of opioids. This allows them to identify all opioid prescriptions, which can reduce the likelihood of using multiple providers or overusing the emergency room to get opioids. Not all states have PDMPs at this time, but implementing this should help reduce overuse of opioids.
At every meeting I attend about the current opioid epidemic members state that more treatment slots are needed. While I believe this is true, usually the discussion is on residential treatment. However, without long-term outpatient follow up after individuals complete a residential program, the risk of relapse increases. In psychiatric care, recurrent major depression has three phases of treatment: acute, continuation, and maintenance. The idea is that affected individuals can remain in long-term treatment after they are clinically stable as a way of reducing the risk of recurrence. Current treatment practices in outpatient addiction programs seldom include long-term follow up. In fact, many individuals are advised to attend ninety meeting in ninety days. While NA and other Twelve Step mutual programs are excellent sources of support, not all individuals will engage in or use these programs. Other options are needed, including longer-term outpatient medical or addiction care with a professional caregiver. This provides individuals with OUDs the opportunity to address issues such as depression and trauma that may have contributed to or resulted from their OUDs.
Short-term use of MATs, especially buprenorphine, is often insufficient in many individuals with OUDs. This also speaks to the need for longer-term involvement in ongoing treatment for those with an OUD who need MAT to support recovery.
Education on the use of naloxone to reverse potentially fatal overdoses has helped save many lives. This education is needed by addicted individuals, families, significant others, treatment providers, and first responders like police, EMS personnel, and others. Easy access to free naloxone kits is one way of having more people ready to help those who overdose. Several months ago I attended a meeting in our Capitol in which police were recognized for nearly seven hundred overdose reversals using naloxone. However, not all police departments or officers are open to the idea of administering naloxone to people who have overdosed.
I believe there is another opioid epidemic issue that is not receiving sufficient attention: the effect on families and children. Families are the ones who most often deal with the many burdens and complications of OUDs and other addictions, often without resources they need. Family members worry about overdoses, relapses, incarceration, and their loved ones being unable to function as responsible members of society. They do many things to try to help, some of which do not work, and they often feel emotionally exhausted. Some experience serious financial problems. Families and children need to be included in the service delivery system so they have an opportunity to be heard. They need help dealing with stress, managing their own emotions and behaviors, and getting connected with others who can understand, support, and help them. They deserve easier access to treatment and recovery.
We all need to pitch in to help with this major problem. Despite any limitations of current provider systems, there is still much that can be done to alleviate the effects of this problem and make a difference in the lives of addicted individuals and their family members.