Reducing Opioid Abuse is Half the Battle

Opioid Addiction

Opioid addiction is one of the most distressing and difficult diseases to treat in medicine. The patient has a disease not a personal failing. This is critical because the most effective means of treating opioid addicting is through the disease concept. It has been found that an opioid patient is generally very bright and this makes the treatment more difficult.

Personal judgement only makes the disease worse, as it is shame based behavior. Making the patient feel bad about a personal failure continues a cycle of (a) drug use to make feel better, (b) treatment in which patient is told how bad they are, (c) patient feels ashamed and bad, then cycles back to (a) drug use to feel better. The cycle continues to repeat over and over.

The epidemic of opioid use might start with prescription drugs or street (illegal) drugs, but no matter the starting point the disease has a natural history. It is addiction which is progressive and deadly—Unless the cycle is broken.

We know about the disease of opioid addiction and the difficulty treating it. The best treatment is prevention. That prevention must focus on educating the public, the supply of opioids – prescription and street, and treatment of addicted individuals

Education

How do we educate people, and show the dangers and end results of opioid use? We need more education in schools, but education begins in the home. Through programs like PROMPT TN[1] and national resources tools can be provided to schools, and parents[2] about opioids and addiction. Schools as well need to provide education to students on what is happening in their communities. This is particularly important in regard to students impacted by addicted family members. There is not a lack of motivated teachers that want to help students influenced by the opioid crisis. Many heartbreaking stories of dedicated teachers doing everything in their power to continue communicating with these students, and we need to provide them with support.[3] Some schools have gone so far as to introduce the HOPE program for grades K-12. It is a series of lessons to help kids cope with the impacts of addiction that may exist in their home life.[4]

The most dangerous of all the opioids are heroin and fentanyl. Review of literature finds a list comprehensive resource to help keep our children safe from this deadly drug combinations. Young people are especially prone to temptation to try these drugs, usually leading to a rapid addiction. This included reference paper is “worth its weight in gold” for educating parents, children, teens, and young adults. Few individuals are exceptions to the rapid addiction and this reference proves the case.[5]

Supply

The sources of drugs which fuel the addiction problem are both illegal and legal. Illegal opioid drugs have been an issue for hundreds of years. Legal sources are a more recent issue with the wide spread use of pain medication developed for cancer patients being prescribed for noncancer pain management.

Opium and heroin are the best known natural opioids, drugs that society has been dealing with for years. Natural opioids generally come from the poppy plant, and the drugs are made of the product of the poppy. Joining the natural opioids are synthetic opioids, namely fentanyl. There are a number of these types of drugs, but they all have similar properties and are compounded from various chemicals. Fentanyl was invented in the 1960s and was principally utilized during surgical procedures. All of these opioid derivatives are now street drugs sold illegally.

Treatment

The opioid use disorder diagnostic standards and treatment of chronic pain is difficult because most patients deny that there is a problem. The reference article gives examples of treatment options, but moreover dialog to “break them” the patients denial of any problem.[1]

Adult treatment opioid use disorder follow two basic protocols.

  1. Detox and opioid withdrawal syndrome is a medically supervised withdrawal. These can be a taper controlled decrease in opioids; methadone or buprenorphine tapers are tapering of an opioid substitute.

  2. Maintenance approaches with methadone or buprenorphine both work for medically controlled withdrawal and maintenance.[2]

  3. The combination of medical and behavioral therapy called MAT (Medical Assisted Therapy) is a two-stage approach. The medical therapy is to help with detoxification and stabilization while behavioral therapy is used to prevent relapse into opioid use disorder.[1]

  4. There are many combinations of treatment and each patient should have the combination that the treating health care provider and counseling team deems appropriate and best.

The combination of medical and behavioral therapy called MAT (Medical Assisted Therapy) is a two-stage approach. The medical therapy is to help with detoxification and stabilization while behavioral therapy is used to prevent relapse into opioid use disorder.[1]

There are many combinations of treatment and each patient should have the combination that the treating health care provider and counseling team deems appropriate and best.

Public Health Emergency 

In March 2019, the Journal of Health Systems – Pharmacy published an article on the origins, trends, policies and rolls of pharmacists in the opioid crisis[1]. It lays out the origins of the opioid crisis and goes on to make policy recommendations related to pharmacists and their role in managing patients in order to reduce and eliminate this problem.

In October 2017, the opioid crisis in the United States was declared a national public health emergency.[2] The U.S. Department of Health and Human Services (DHHS) announced several priorities to combat opioid misuse, including “improving access to treatment and recovery services, promoting use of overdose-reversing drugs, strengthening our understanding of the epidemic through better public health surveillance, providing support for cutting-edge research on pain and addiction, [and] advancing better practices for pain management goal of improving patient outcomes.[3]

The key points of the study were:

  • In the United States, 1 in 7 individuals will develop substance addiction, and for patients prescribed opioids for chronic pain, 21% to 29% will misuse them and 8% to 12% will develop an opioid use disorder.

  • Due to specialized training in medication safety, management, and monitoring, pharmacists are uniquely qualified to participate in initiatives addressing appropriate management of prescription opioids; therefore, many governmental, health-care associated, and pharmacy-associated entities require or encourage pharmacist participation in addressing the opioid crisis.

  • Pharmacists can participate in preventing, managing, and treating opioid misuse through prescription drug monitoring programs; interventions in community, outpatient, and inpatient settings; overdose prevention; and education on abuse-deterrent formulations of opioid analgesics.[4]

The origin of the opioid crisis can be found in policies developed in the mid 1980s that supported and encouraged the use of opioids for management of noncancer pain. In the mid-1990s the American Pain Society and the American Academy of Pain Medicine endorsed the use of opioids to treat chronic noncancer pain, and promoted the relief of pain as a vital sign of improved patient care. These policies we adopted by federal agencies like the Veterans Affairs. Since that time, the VA has withdrawn its support of these policies. [1]

Following advocacy efforts such as the “pain as the fifth vital sign” campaign and the marketing campaigns of pharmaceutical companies, state medical boards loosened restrictions on prescribing opioids for treating chronic noncancer pain.[2]This led to a dramatic increase in the number of opioid prescriptions in the United States. Retail sales of oxycodone and hydrocodone increased skyrocketed. Oxycodone and hydrocodone prescriptions increased by 866% and 280%, respectively, from 1997 through 2007. Likewise, from 2000 through 2009, the total number of immediate-release opioids dispensed by outpatient pharmacies in the United States increased from 164.8 million to 234 million and extended-release opioids dispensed increased from 9.3 million to 22.9 million. Moreover, the United States leads the world in overall consumption of narcotics, including the global supply of hydrocodone (99%) and oxycodone (83%).[3]

This high volume of opioid prescribing contributed to the abuse and deaths caused by opioids. In 2012, at the height of this high volume of prescription writing, the rate per 100 people in the U.S reached 81.3, in 2017 that rate had fallen 58.7. About 25 percent of all persons prescribed opioids abuse them, and about 10 percent develop opioid use disorder.

Drug Abuse after Prescription Opioids

As local, state and federal authorities began cracking down on the over prescription of opioids to thousands of people, those individuals were forces to turn to other sources. Over 80 percent of persons who use heroin, first misused opioids. While death rates from misuse of prescription opioids has decreased in recent years, the death rates for use of heroin and fentanyl continue to increase. We have merely substituted the addiction to prescription drugs to addiction to illegal drugs. Tennessee is in the heart of this addiction problem.[1]

Tennessee

Tennessee has an issue with opioid drug abuse.  The help from Washington to detail and combat the prescription drug problem has had an impact. The impact however has been the shifting of addiction from prescription drugs to street drugs

Tennessee has been an outlier in the fight against opioid abuse.  The CDC reports that nationwide overdoses fell more than 4% in 2018.  States near Tennessee, like Ohio, Pennsylvania, West Virginia, and Kentucky, saw overdose deaths drop as well.  The figures indicate while overdoses to prescription opioids are falling they are being replaced by fentanyl and heroin deaths. Dr. Howard Taylor, a lab director for the American Addiction Centers in Brentwood, says that we lack both quantity and quality of treatment centers.

Tennessee like other states has decreased the overall amount of opioid prescriptions, but that has led people who were dependent on the prescription drugs to other more dangerous avenues.  Since 2012, Fentanyl deaths have risen from 77 to nearly 600, and heroin deaths have gone from 50 to over 300.

Solutions 

Solutions for opioid addiction cannot be dictated from Washington. It’s the federal government’s job in this case to provide guidance and funding to state and local government to deal with a community based problem.

  1. Congress and the executive branch need to create a program that awards “Block Grants” to states and local governments.

  2. States must establish standards for how local jurisdictions will utilize the funds. 

  3. For local governments to receive federal funds, they must develop comprehensive programs that are tailored to their community and are designed to reach people uniquely impacted by opioid addiction and request funding to implement their plans.

Programs developed at the local level should focus on addressing eight categories of activities to quell the spread of opioid abuse and provide affected people with solid rehabilitative programs.

The eight categories of activities a local Opioid Addiction Program must contain are:

  1. Law Enforcement

  2. Reducing the flow of Opioids and Alternatives

  3. Providing Opioid Reversal drugs

  4. Treatment Programs

  5. Pain management

  6. Community Partnerships

  7. Peer Support

  8. Overcoming Stigma

Law Enforcement and Prevention

  1. Increased support for local law enforcement and coordination with state and federal authorities is critical in addressing the availability of illegal opioids for those that became addicted due to prescription drugs. The prosecution of drug dealers should be particularly harsh for those who sell heroin and fentanyl drugs. The goal is get these drugs “off the streets.”

  2. Expand the medical provider registry to all states (using the Tennessee model). All providers of controlled substances are registered and work in combination with pharmacies to discover forged prescriptions. Also, a statewide data base has been established in Tennessee for providers to check for patients “doctor shopping” for multiple drug prescriptions.

  3. Place more stringent monitoring standards on “pain clinics” in place. Develop stringent “audit procedure” with reporting and state certification dependent on adhering to known criteria for opioid drug prescribing.

Reducing the flow of opioids

Preventing a new generation of individuals from being exposed to dependency on opioids in an important part of the overall solution. Lowering the prescription rate is critical for noncancer pain management. It must be done in connection with accessible and affordable alternative treatments.

Before people become patients, who are addicted, develop a “high risk for addiction” evaluation. This will be a series of questions in the patient data form that will alert healthcare providers as to degree of patient risk for drug addiction behavior.

The questions for screening will be such that they are stealth in the intake form and will be developed with a team of addiction specialists.

Thus, the most important factor in opioid abuse can be identified. It is not the drug or prescriber. It is identifying the high-risk person and treating accordingly.

 

Opioid reversal drugs

Naloxone is a drug that reduces the effects of opioid overdose. It saves lives and reduce the effects of overdose when administered as soon as possible. This drug needs to be provided to police and EMTs who can when they are called upon to assist and overdosed individual, administer the drug as front line defense for the person in danger and for the benefit of the community.

Treatment programs

Provide for rural hospitals with the tools to treat immediate emergencies and be a focal point for intensive community detox programs and move people back into active and functioning lives. It is critical to provide rural areas in particular with high quality medication-assisted treatment.

Pain management programs

Training of medical providers in all areas of the community with better pain management programs. From the doctor’s office to emergency rooms, a clear protocol for use of any pain medication based on the type of pain and time frame of expected use.

Peer support

Local community plans need to provide peer support programs that can provide help to struggling addicts. Peer recovery coaches are low-cost ways to provide needed open lines of communication for patients coming to hospitals and clinics for substance abuse issues. Most communities have these programs that address alcohol and narcotic abuse.

Community partnerships

Plans need to coordinate the activities of the local community. The community providers include the health care system, mental health services, the criminal justice system and social welfare organizations. These organizations can work together to provide a holistic approach to addiction and recovery.

Overcoming stigma

This opioid crisis carries with it the same stigma that has long been held with drug addiction. That stigma is that it is a crime, mental health or character flaw condition. Opioid use needs to be treated as chronic disease. These persons were over prescribed addictive drugs by medical personal. The community needs to come forward and provide the proper support to these persons to regain their humanity and end the substance abuse.

Paid for by Friends of George Flinn 2020

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