The Opioid Epidemic: A National Public Health Emergency

Background

In 2016, the Centers for Disease Control (CDC) declared opioid-induced deaths as a national epidemic.

• 91 Americans die every day from an opioid overdose.
• Drug overdose is now the leading cause of unintentional death of people under age 50 in the U.S.
• More than 64,000 people died of drug overdoses in the U.S. in 2016, up 22% from 2015.
• Opioids have been prescribed for pain mitigation for nearly 25 years. During the 1980s and 1990s, education to de-stigmatize opioids and increase comfort in prescribing inadvertently contributed to the growth in opioid prescribing.

How Did We Get Here?

• The American Medical Association suggested Joint Commission standards for recognizing pain as the “5^th Vital Sign” to encourage more opioid prescribing practices.
• Belief that long-acting opioids (e.g., MS Contin and OxyContin) were safe.
• Increased marketing by pharmaceutical companies.
• Pill mills by unscrupulous prescribers started to pop up.

Then:

• Consensus emerged, two decades into the pain revolution, that opioids were unhelpful, even risky for some types of chronic pain (e.g., back, headaches, fibromyalgia).
• Decrease in supply of prescription opioids without addressing the continual demand for patients who continue to be dependent and/or are having chronic pain issues.

Here We Are: Opioid Epidemic

Today, the majority of heroin/fentanyl users report their opioid misuse began with prescription drugs.

• Heroin laced with fentanyl and other drugs has increased its capacity to cause death.
• Lower price of heroin and decreasing access to prescription opioids increased heroin use.
• Abuse deterrent formulation of OxyContin made it harder to inject, causing some to switch to heroin.
• Among new heroin users, approximately three out of four report abusing prescription opioids prior to using heroin.
• The increased availability, lower price, and increased purity of heroin in the U.S. have been identified as possible contributors to rising rates of heroin use.

Opioid Crisis in North Carolina

According to the North Carolina Department of Health and Human Services (NCDHHS) and the CDC, North Carolina has experienced a 350% increase in drug overdose deaths since 1999.

• North Carolina is one of 19 states that saw a statistically significant increase in drug overdose death rates from 2014 to 2015.
• The #1 city in the U.S. for opioid abuse is Wilmington, NC.
• One-third of narcotic prescriptions in NC get diverted.
• The North Carolina Medical Board (NCMB) suggests the use of NC controlled substances reporting systems.
• NCMB passed a Public Health Law to require prescribers to complete required course work on pain management and addiction.
• This epidemic is devastating families and communities.
• It is overwhelming medical providers and is straining prevention and treatment efforts.

The STOP Act

North Carolina Governor Roy Cooper signed the “Strengthen Opioid Misuse Prevention (STOP) Act” into law on June 29, 2017 which is aimed at curtailing the opioid abuse epidemic in NC. The objective is to reduce or eliminate inappropriate opioid prescribing.

The STOP Act applies to all “targeted controlled substances” (all Schedule II and Schedule III opioids or narcotics).

Effective Jan. 1, 2018, the STOP Act establishes limits on initial prescriptions for:

• acute pain, a 5-day supply
• post-surgical pain, a 7-day supply

Rationale

Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.

The STOP Act defines “acute pain,” whether resulting from disease, accident, intentional trauma, or other cause, as pain expected to last for three months or less. This includes post-surgical pain and pain generated from injuries of all types.

The Case For Opioids

The STOP Act does not include chronic pain or pain being treated as part of cancer care, hospice care, palliative care, or medication-assisted treatment for substance use disorder. Medications are prescribed for the treatment of cancer or another condition associated with cancer. This provision does not apply to prescriptions issued by practitioners ordering targeted controlled substances to be wholly administered in a hospital, nursing home, hospice facility, or residential care facility.

Chronic Pain Management

Periodic North Carolina Controlled Substances Reporting System (NC CSRS) reviews should be conducted every three months after the initial prescription.

Rationale

Prior to prescribing a Schedule II and Schedule III opioid or narcotic, practitioners are required to review a patient’s 12-month prescription history in NC CSRS.

For every subsequent three-month period that the Schedule II or Schedule III opioid or narcotic remains part of the patient’s medical care, practitioners are required to review the patient’s 12-month history in the NC CSRS.

Reviews should be documented within the patient’s medical record, along with any electrical or technological failure that prevents such review. Practitioners are required to review the history and document the review once the electrical or technological failure has resolved.

Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation and should evaluate benefits and harms of continued therapy with patients every three months or more frequently.

CDC Guidelines

CDC guidelines include the exception of patients receiving active cancer treatment, or palliative care and end-of-life care. Some benefits of opioids for those suffering acute pain include:

• The release of neurotransmitters notifying the body of pain is inhibited.
• Carbon dioxide receptors in the lungs become less sensitive, causing respirations to slow, thus allowing for deeper breaths.
• Blood flow to the heart and lungs is increased.
• Relaxation improves.

Opioids: Myths and Facts

MYTH

“Do not give my father morphine for his cancer pain. You are assisting in his death by stopping his respirations!”

FACT

While respiratory depression is the main possible hazard of all opioids, opioids are gold standard in the treatment of dyspnea (shortness of breath).

MYTH

“I will not prescribe morphine for my patient with advanced COPD with shortness of breath – she is not on hospice.”

FACT

Opioids can be used for advanced dyspnea management for many disease states, not just for management of end-of-life refractory dyspnea.

MYTH

“No morphine, I do not want my mother to become a drug addict!”

FACT

Fears about psychological dependence (addiction) are often exaggerated when opioids are used to treat severe pain or dyspnea.

The abuse of opioids is rarely seen in patients with cancer or other severe pain, nor do these medications lead to addiction in terminally ill patients.

Medical professionals can screen for risk factors: a family history of addiction, a personal history of alcohol and drug abuse, or certain psychiatric disorders. Use of recreational drugs increases likelihood of prescription pain medication addiction.

–Christine Khandelwal, DO
Director of Inpatient Palliative Medicine
Transitions LifeCare

For more information:

• Centers for Disease Control and Prevention: Opioid Overdose Website
• STOP Act slide deck
• North Carolina Medical Board: Opioid Prescribing

References:

• Marciniuk DD, Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian Thoracic Society Guideline. Can Respir J 2011; 18(2). We recommend that oral (but not nebulized) opioids be used for the treatment of refractory dyspnea in the individual patient with advanced COPD. (Grade of recommendation 2C) Ben-Aharon I, Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. Acta Oncol 2012; 51(8): Our systematic review and meta-analysis demonstrate a beneficial effect to opioids in alleviating cancer-related dyspnea, and no advantage for the use of oxygen.
• Canadian Thoracic Society Guidelines From Marciniuk D, Goodridge D, Hernandez P, et al. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian Thoracic Society clinical practice guideline. Can Respir J. 2011;18(2): Reprinted with permission.
• Patients should be asked to rate the intensity of their breathlessness as part of a comprehensive care plan, opioids should be dosed and titrated for relief of dyspnea in the individual patient, American College of Chest Physicians Mahler DA, Chest. 2010 Mar;137(3).
• Open, uncontrolled trial in 20 terminal ca pts, 5mg or 2.5 x reg95% reported less dyspnea. No change in respiratory rate or effort. No change in arterial O2 sat or end-tidal PaCO2. Bruera E J Pain Symptom 1990; 5(6): Crossover Placebo Controlled Trial. 10 consecutive ca pts on stable opioid. Dose increased 50% (avg 34.5 mg sc) Good relief, no resp depression Bruera E Ann Intern Med 1993; 119:906. Randomized double-blind trial. 9 elderly cancer patients received either 5mg sc or 3.75mg more than regular dose. In 45 min sig lower mean dyspnea by VAS & Borg scales No changes observed in respiratory effort or rate, No change in O2 sats Mazzocato C, Ann Oncol. 1999; 10 (12).
• 14 palliative care patients with dyspnea all treated with hydromorphone and carefully monitored In 30 minutes, average dyspnea dropped 5.2 to 1.1 on 10 point scale. Respiratory rate decreased 39 to 35 breaths / minperipheral oxygen saturation unchanged transcutaneous arterial pressure of carbon dioxide unchanged Clemens KE, Support Care Cancer. 2008; 16(1): 93-9
• Bercovitch M, Waller A, Adunsky A. High dose morphine use in the hospice setting: a database survey of patient characteristics and effect on life expectancy. Cance, 1999; 86: 871–77 9 Morita T, Ichiki T, Tsunoda J, et al. A prospective study on the dying process in terminally ill cancer patients. Am J Hosp Palliat Care 1998; 15: 217–22. 10 Morita T, Tsunoda J, Inoue S, Chihara S. Effects of high dose opioids and sedatives on survival in terminally ill cancer patients. J Pain
  Symptom Manage2001: 21: 282–89.
• Thorns A, Sykes N. Opioid use in the last week of life and implications for end of life decision-making. Lancet 2000; 356: 398–99.