I recently got into a conversation about the opioid epidemic with my sister who is a doctor and an OBGYN, and gave birth this year via a Caesarean (a/k/a C-section). She shared some eye-opening insights about her own personal experience and the changes in prescription practices at the big city public hospital where she is the chief resident. The good news is that prescription practices are clearly heading in the right direction. A typical mother leaving the hospital will be given one week’s worth of Percocet for the pain after a C-section, while in the past it was for as much as a month. As for my sister, who is keenly aware of the potential for addiction, she got by on just one day of Tylenol 3 after discharge. This greater concern and mindfulness seems to be spreading throughout the country with respect to all opioid prescriptions in general.The US Centers for Disease Control and Prevention noted that the amount of opioids prescribed per capita peaked in 2010 and declined by 18% by 2015, with 13.1% of that decrease coming between 2012 and 2015.
Much of that reduction occurred as a result of increased awareness in the medical community and some key action at the state level. National medical guidelines on opioid use and state prescription drug monitoring databases have played a big role.
Doctors are now prescribing opioids for a shorter duration and in lower doses than they have in the past. Recent focus on “Pill Mills” by the Justice Department has also helped considerably. Three recent high-profile arrests single-handedly eliminated enterprises responsible for the distribution of almost 15 million opioid tablets. Nonetheless, the amount of opioids prescribed in 2015 is still triple the amount of opioids prescribed in 1999. It seems we still have ways to go before we can start patting ourselves on the back. Another pressing issue is that lower prescription rates have merely pushed people who are addicted, to heroin and other illicit street drugs, instead of toward treatment. I’ve written about this a number of times before, because it’s so important. Many unsuspecting people with legitimate pain issues inadvertently become addicted through exposure to opioids. When a responsible doctor then cuts them off, they turn to more dangerous options. The main problem is two-fold. Doctors typically don’t ask patients about past history of addiction in the family in an H&P (History and Physical) like they would for heart disease or diabetes.That’s a big omissionbecause addiction in a parent is highly predictive of potential addiction in a child; 40% if one parent was an addict, 70% if both were. Moreover, these Patients-came-addicts don’t inform their doctor about the problem once it arises.
The vast majority of people who are prescribed opioids, over 90%, do not become addicted, so most doctors do not focus on the importance of asking patients whether they need addiction treatment, once the prescription has run its course. Most mothers’ post-caesarean do not have an issue, whether given 7 or 30 days worth of pain killers. However, for the less than 10%, who are pre-disposed to the disease of addiction, it can be tragic and fatal. Opioids, heroin and fentanyl have that kind of grip on them. These people did not choose to become addicted by purposely ingesting something to trigger their disease, they mostly had addiction thrust upon them.
I had a kidney stone last year; it was the most painful experience I’ve ever had. Some people describe it as similar to giving birth. I left the hospital with 30 days of oxycontin, prescribed by a well-meaning specialist concerned about my pain. I took it for one day and turned in the rest to my local pharmacy, deciding to grin and bear it. Just like my sister, I didn’t want to take any chances because addiction runs in our family and I know better than to put myself at that kind of risk; most people don’t. It got me to thinking that every prescription of opioids should come with a mandatory warning directly from the doctor or the requirement of viewing a brief video on the dangers of addiction from opioids. At least we’ll be doing something proactive about solving this problem and saving lives in the process, and with today’s smartphones, it’s an easy implementation. There are some other measured advances that also give us hope.
Under the Comprehensive Addiction and Recovery Act, federal spending to combat the opioid epidemic has increased 542% at Health and Human Services and 113% at the Justice Department. The 21st Century Cures Act approved $1 billion of additional spending toward this problem, over a two-year period. Even recent Republican proposal on healthcare proposed as much as $45 billion to specifically combat opioid abuse, spread out over 10 years. But, as their fellow Republican and likely 2020 primary candidate, Ohio Governor John Kasich noted, it’s “like spitting in the ocean,” not nearly enough. The issue has become so pervasive that even the Federal Reserve Bank and large investment banks are weighing in on the subject. Goldman Sachs came out with a recent report indicating that US workforce, and economy in general, is being dragged down by opioid abuse; something I wrote about back in June.
So, Where Does This Leave Us?
Addiction is a disease, but as with all diseases, it requires a group effort. A combination of government funding for research, private enterprise, informative education from doctors and, ultimately, personal responsibility by individuals, has turned AIDS from a death sentence that killed 49,000 people in 1995, into a very treatable disease that most people now survive. That’s exactly the type of strategy and attention demanded by addiction. As addiction treatment professionals we can help influence public policy, increase awareness throughout general medical care and do our own part directly, utilizing the strengths of our organizations. However, we must also emphasize the importance of individual responsibility to our patient-addicts if we are ever going to swing the pendulum in our favor. Much like my sister and I, who made conscious decisions not to take chances with opioids, and the AIDS, diabetic and cancer patients who actively pursue treatment, we need to create an environment of like-minded thinking; our patients need to do their part. If someone has a problem with addiction he needs to let his doctor know in advance; or if he discovers he’s becomes addicted during treatment, as soon as it presents itself. Helping to remove the shame and guilt; the stigma associated with the disease of addiction, will certainly help. We must also find additional ways to more greatly encourage both doctors’ and patients’ active engagement. The earlier we catch addiction, the easier and cheaper it is to do something about it, and the fewer lives it leaves in ruins. We need everyone’s contribution to finally start putting addiction in its place.