Pain and the Opioid Epidemic: Stemming the Tide of Addiction and Preventable Deaths
By Andrew Mendenhall, M.D.
Medical Director
Hazelden at Beaverton
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Original Publish Date: October 31, 2014
We are in the midst of a serious epidemic, the likes of which I’ve never seen.
During the last decade, 125,000 people in our nation died from overdose of prescription painkillers. That compares to 58,000 who died in the Vietnam War.
In the most vulnerable group (35-54 years), more people die each year from prescription opioids than from firearms and car accidents combined.
The cost
As physicians prescribe more painkillers to keep patients pain-free, we see a corresponding rise in addiction treatment center admissions, emergency room admissions due to overdoses and deaths caused by overdose of opioids.
- Between 2000 and 2012, Oregon’s death rate from opioid overdose quadrupled.
- In 2012, 1,500 Oregonians were hospitalized due to drug abuse. Of those, nearly a third were due to prescribed opioids.
- In 2012, medical care due to overdose from all drugs cost Oregon hospitals more than $31 million. That doesn’t take into account the cost to employers, the loss of productivity to society and the emotional drain on individuals and families.
This epidemic is preventable
The greatest tragedy is this epidemic is preventable. You and I, as health-care professionals, have the power to stop this terrible epidemic.
Yes. Of course. Opioids can be incredibly useful for treating acute pain, for example, pain from a broken leg. But we’ve gone overboard on when and how we use opioids. U.S. doctors prescribe 99 percent of the world’s supply of hydrocodone. I know kids whose doctors prescribe opioids for sprained ankles and minor injuries.
New policy
According to a new policy statement, published Sept. 30, 2014, by the American Academy of Neurology, the risks of death, overdose, addiction and serious side effects with prescription opioids far outweigh their benefits in chronic pain, non-cancer conditions such as headache, fibromyalgia and lower back pain.
While opioids may provide significant short-term pain relief, the AAN reports neither substantial evidence for maintenance of pain relief over long periods of time nor significant evidence of improved physical function without serious risk of overdose, dependence or addiction.
Studies show 50 percent of patients taking opioids for at least three months are still on opioids five years later.
The premise that tolerance can be overcome by dose escalation is seriously questioned. The AAN recommends doctors consult with pain management specialists if dosage exceeds 80 to 120 (morphine-equivalent dose) milligrams per day, especially if pain and function have not substantially improved in patients.
Moreover, in a new national survey, sponsored by the Center for Public Advocacy at the Hazelden Betty Ford Foundation, Americans with chronic pain say current treatments using prescription painkillers don’t work, leading to years of intense suffering, thoughts of suicide and often dependence on the medications. Nearly eight in 10 (79.5 percent) of those medicated for pain are willing to reduce or eliminate their current medications and try an alternative treatment for chronic pain.
The Hazelden survey also shows doctors are prescribing addictive medicines to people with a history of addiction. Nearly half of those surveyed (48.2 percent) take three or more pain medications.
Treating addiction
Prescription opioids are now the fastest growing addiction problem in the U.S. and have replaced illicit drugs as the leading cause of drug-related death.
Alcohol remains the major reason people seek treatment for addiction. But opioids are now the second drug of choice. (40 percent for ages 14 to 24; 30 percent for adults).
In response, the Hazelden Betty Ford Foundation has changed the way it treats people who are addicted to opioids. We use two medications: Vivitrol, an opiate receptor block to prevent intoxication if a client uses opioids, and Suboxone, which, like methadone, is used daily for maintenance treatment of opioid dependence.
We recognize clients need long-term treatment and may suffer physiological changes for six to 12 months. And we’ve changed how we educate patients. We describe the very real risk of death associated with relapse. Once they stop taking opioids, their tolerance drops quickly. If they go back the same dose they were taking, it can kill them.
Stemming the tide
We must work together to stem the tide of this devastating epidemic. All patients who take daily opioids are "physically addicted," meaning dependent on the presence of the medicine to avoid withdrawal. All opioids are potentially addicting: four out of 10 people taking daily opioid therapy regularly misuse or abuse their medicines. We need more safeguards to limit use to moderate to severe acute pain. We need:
- To educate physicians and our entire health-care workforce, beginning in medical and nursing schools, about the dangers of opioids and its affect on the brain.
- To require all states to have a mandatory Prescription Drug Monitoring Program (PDMP) for scheduled opioids. Studies show it’s used only a third of the time in states where it isn’t mandatory.
- To screen for addiction and alcoholism in a patient’s family history. This is a major risk factor, and it’s a simple question.
- To better understand chronic pain and its treatment so people have appropriate resources.
- To reduce the seawall of pills in our community through safe disposal sites and drug-take-back events.
- To get people who become addicted into treatment programs as soon as possible and to remember addiction is a brain disease and not a moral failing. Treat it like a disease.
Every patient who takes prescription opioids for pain for more than 30 days is physically dependent. All deserve the opportunity to detoxify and receive recovery support from their painful condition and the brain chemical imbalance that occurred from long-term opioid therapy.
Doctors helped patients become dependent. Doctors and health systems need to provide access to services so more patients may “unscript” themselves from these powerful and risky medications.
We need to work together – patients, health care-executives, physicians, pharmacists, pain specialists, recovery treatment specialists, law enforcement and communities. This is an epidemic we can overcome.
Andrew Mendenhall, M.D. is the medical director of Hazelden in Beaverton, part of the Hazelden Betty Ford Foundation, with particular expertise in medical detoxification. Dr. Mendenhall specializes in the complex care needs of patients with co-occurring mental health, pain management and addiction medicine issues. He holds board certification by the American Board of Addiction Medicine and the American Board of Family Medicine. He is a diplomate of the American Academy of Pain Management.