Opioid misuse, abuse and overdose have reached epidemic proportions and have created a crisis in health care for patients, their families and the entire community. Opioids include hydrocodone, oxycodone, morphine and codeine. Although opioids are an important tool for the management of chronic pain in the outpatient and community settings, the dramatic escalation in outpatient prescriptions for and misuse use of these drugs has contributed to addiction, overdose and related deaths, as well as diversion for improper or illegal use.
Economic impact of the opioid epidemic:
An estimated $55 billion is attributed to healthcare and social costs related to prescription opioid abuse each year and $20 billion in emergency department and inpatient care for opioid poisonings (HHS 2016).
Opioid-related deaths have skyrocketed
This rise in opioid overdose deaths can be outlined in three distinct waves (see Figure). The first wave was related to increased prescribing of opioids in the 1990s involving prescription opioids (natural and semi-synthetic opioids and methodone) including oxycodone and hydrocodone. The second wave began in 2010 with deaths related to heroin. The third wave most recent wave began in 2013 involving synthetic opioids, particularly those involving illicitly-manufactured fentanyl.
Deaths related to fentanyl The most recent wave of the opioid epidemic and related deaths have increasingly involved illicitly manufactured fentanyl (a synthetic opioid) and a wide array of highly toxic fentanyl analogs and the combination of these fentanyl analogs with heroin, cocaine, counterfeit pills and benzodiazepines. The CDC has issued their third opioid-related Health Alert -July 2018–warning of a sharp increase in deaths from these drugs, including the ultra-high potency fentanyl analog known as carfentanil. The Health Alert provides guidance includes specific guidance on preventing occupational exposure for law enforcement, emergency responders and laboratories, as well as prevention and response efforts for public health professionals and health care providers.
Deaths related to heroin. Between 2010 and 2016, heroin related overdoses increased by a factor of five.Contributing to these deaths is the use of heroin in combination with other drugs. Nearly all people who use heroin also use at least one other drug, such as cocaine and a prescription opioid pain reliever.
Deaths related to prescription opioids. According to the CDC, Overdose deaths involving prescription opioids as well as sales of prescription opioids in the U.S. nearly quadrupled since 1999, but there has not been an overall change in the amount of pain Americans report. From 1999 to 2015, more than 183,000 people have died from overdoses related to prescription opioids. . During 2015 alone, drug overdoses accounted for 52,404 U.S. deaths, including 33,091 (63.1%) that involved an opioid.
The problems with prescription painkillers
To put this in perspective, health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills CDC.
A recent study of office-based physician visits found that opioids were prescribed almost twice as often as a decade previously. Physicians prescribed opioids in almost 20 percent of visits for pain with prescribing rates increasing more for family practice, general medicine and internal medicine compared to other specialties.
Overprescribing of opioids after surgery adds to the problem
Opioids have been used for centuries and remain the most potent and reliable analgesic agents used routinely and effectively for the treatment of acute severe pain following trauma, extensive burns or major surgery. The concern and dilemma for prescribing clinicians is with their use for chronic non-malignant pain because of their potential for abuse and addiction.
Recent studies suggest that opioids are over-prescribed for pain after dental and other types of lower risk surgery. It is estimated that 12 percent of all immediate release opioid prescriptions are written by dentists in the U.S. In a large study of over 2.7 million Medicaid patients, a disproportionately large amount of opioids were prescribed after tooth extraction, given the expected intensity and duration of post-extraction pain. In this study, 42 percent filled a prescription for an opioid pain medication within 7 days of a tooth extraction and opioids were dispensed more often (61 percent) for teens aged 14 to 17 (JAMA 2016).
A similar study looked at opioid prescribing for 14 million patients who had surgery for carpal tunnel syndrome, gall bladder removal and hernia repair or knee arthroscopy. Eighty percent of those patients filled a prescription for an opioid pain medication within 7 days of being discharged from the hospital (JAMA 2016).
A 2017 study in JAMA-Surgery found that 6 percent of 36,177 patients without opioid use in past year who were prescribed opioids for minor to major surgical procedures were still on opioids 3 months later, long after most should have recovered. There was no difference in long term opioid use between those who had minor vs major surgical procedures. Extrapolated to just the 50 million outpatient procedures each year, this represents up to 3 million that may become newly dependent on opioids.
Prescribing guidelines in a recent CDC Guideline released in March 2016 state that acute pain “can often be managed without opioids” and suggest that “three days or less will often be sufficient; more than 7 days will rarely be needed.”
Options for post-operative pain
American Pain Society recently released guidelines that suggest a multi-modal approach to treatment of post-operative pain that includes a multi-modal approach that can be used along with opioids if needed. For example, it might include a combination of non-opioid medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), regional anesthesia (e.g., nerve blocks) and other approaches (e.g., passive motion, pre-operative education on options for pain management). This approach will help reduce the risk of post-discharge long term use, dependence and addiction.
Diversion for improper use
While many people benefit from using opioids to manage pain, prescription drugs are frequently diverted for improper use. In the 2017 National Survey on Drug Use and Health (NSDUH), 53.1% of people who misused prescription painkillers got them from a friend or relative for free, and 34.6% got them from a single doctor. According to the National Survey on Drug Use and Health (NSDUH) – 2017, 11.1 million people (age 12s and above) misused prescription pain relievers in the previous year.
As people use opioids repeatedly their tolerance increases which can lead to physical dependence and addiction and they may not be able to maintain the source for the drugs. This can cause them to turn to the black market for these drugs and even switch from prescription drugs to cheaper and more risky substitutes like heroin.
The epidemic of addiction to opioids is also the major driver of drug diversion in healthcare facilities (employee stealing for their own use) resulting in care delivered by impaired provider, denial of essential pain therapy, and outbreaks from hepatitis C virus or bacterial pathogens when tampering with injectable opioids involving hundreds of patients, according to the CDC. For more information visit our section on Drug Diversion in healthcare facilities.
Prescription Drug Monitoring Programs
Prescription Drug Monitoring Programs (PDMPs) are state-run electronic databases to track the prescribing and dispensing of controlled prescription drugs to patients. They can provide the prescriber or pharmacist critical information regarding a patient’s-controlled substance prescription history to help avoid drug interactions and identify drug-seeking behaviors or “doctor shopping” to identify patients at risk for addiction who might benefit from early intervention. PDMPs are also used to assess for suspected abuse or diversion (i.e., channeling drugs into illegal use).
For more information, visit our section on safer opioid use in the hospitals and inpatient setting and visit our resource section for additional tools and resources.