J Porter, M R Matthews, S Vail
J Porter, M R Matthews, S Vail. The Grim Reaper: Reaping Dividends from the Current Opioid Epidemic. The Internet Journal of Pain, Symptom Control and Palliative Care. 2019 Volume 12 Number 1.
A National Safety Council exhibit, Prescribed to Death: A Memorial to the Victims of the Opioid Crisis, which toured the United States in 2018 was a brutal snapshot of the current opioid crisis.1 Is the real issue illicit drugs or patients initiated on opioid therapy acutely, who progress to illicit drugs for whatever reason? Decreasing prescribed opioids as an effective immediate solution may be an oversimplified approach to a very complex problem that is snowballing out of control and emerging as poly-drug abuse, addiction and suicide.
Why are there so many overdoses?
Pain control, misuse, emotional problems, trauma, substance or opioid use, depression, anxiety, peer pressure, and experimentation contribute to opioid fatalities. Accidental overdose, illegal (designer/synthetic/counterfeit) opioids, easy access to legal and illegal prescriptions, internet and street purchases, suicide attempts and psychiatric illnesses result in systematic poly-drug abuse. Currently, physicians must obtain continued education credits on opioid prescriptions for license renewal, and participate in a prescription monitoring system. The introduction of a “paperless prescription” is another example of immediate solutions provided by the healthcare industry to combat the crisis. Addiction and mis-use of opioids (prescription pain relievers, heroin, and synthetic opioids such as fentanyl and carfentanil) and the statewide legalization of cannabis continue as a serious national crisis that affects public health as well as social and economic welfare.
The previous illicit drug epidemic was introduced by Vietnam veterans returning home from the war and the “golden triangle”, providing multiple “power drugs” to the already primed counter-culture revolution clientele. The simplistic governmental approach to limit the prescription of opioids and public service campaigns such as “Just Say No,” may have contributed to current patients errantly turning to illicit opioids and heroin, due to inadequate prescription opioids for pain, and the belief of safe recreational drugs. This event fueled the resulting addiction to every part of our society in America with years of negative scars. Today’s opioid epidemic is more far-reaching, now encompassing our school age children assisted by the age of rapid information which makes it more powerful in magnitude.
In 2015, overdose deaths from illicit and prescription opioids continued to escalate, and an estimated 2 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers.2 Another 591,000 suffered from a heroin use disorder (which were not mutually exclusive).2 Compared to 2016, 2017 heroin-related overdose deaths declined in the adult population, but increased among seniors (11.6% in the 55-64 year old; 16.7% in the ≥65 year old) and the black population, (8.9%).3 Younger adults were more likely to die from synthetic opioids with the highest death rates in males (25-44 years old). 3 Aging Baby Boomers may be experiencing and reacting to comorbidity sequelae, chronic pain, depression, dementia, and financial retirement issues. It has been observed that overdose–related suicides have been underreported because there has been no routine screening for suicide risk or tailored interventions for suicidal individuals.4 Reports discuss the statistics of adult opiate overdoses as unintentional in approximately 50% by adults and about 20% each as intentional or undetermined.
Poly-drug use has become a public health crisis with devastating consequences and increased ramifications into infections, brain and mental disorders. Increased injections of drugs have contributed to infectious diseases such as HIV and hepatitis. Currently inhaled heroin (chasing the dragon, CTD) has resulted in leukoencephalopathy, and brain injury in the resuscitated patients5. Socially popularized prescription drug smoking (“chasing the bean”) contributes to bronchitis and powerful addiction.6 In addition, the increased statewide marijuana legalization has developed a profitable industry for cannabis growers and sellers with possible future complications in a time of people progressing to poly-drug abuse.7
What are HHS and NIH doing about it?
In response to the opioid crisis, the U.S. Department of Health and Human Services (HHS) is focused on five major priorities: improving treatment, recovery services access, and public health surveillance; better pain management and increased pain and addiction research; and greater utilization of overdose-reversing drugs. On March 18, 2016, the Centers for Disease Control (CDC) published voluntary guidelines for prescribing opioids for patients with chronic pain for primary care physicians. On October 26, 2017, President Trump declared the opioid crisis a national emergency and in February 2018, $6 billion were legislated for prevention and law enforcement in the fight against opioid abuse, with a Prescription Interdiction & Litigation (PIL) Task Force against opioid manufacturers and distributors. In April 2018 at the National Rx Drug Abuse and Heroin Summit, NIH Director Francis S. Collins, M.D. announced the Helping to End Addiction Long-term (HEAL) initiative, for the trans-agency scientific efforts to limit the national opioid crisis. In July 2018, Operation SOS (synthetic opioid surge) was established to eliminate the out of control fentanyl problem imported into the country from overseas.
As Physicians and Healthcare Providers, are we Addressing the Core Contributing Factors in the Opioid Crisis or Should there be a “CALL TO ARMS”?
If there continues to be a United States burgeoning populace demand for the ultimate high with poly-drug pharmacopeias and even legal drugs such as cannabis in some states, there will be an economic follow-up of supply and demand by the cartels and others to either illicitly manufacture drugs in the United States or import them into the country. Limiting exposure to opioids early post-surgery and offering alternative options for pain control may assist in curbing the potentially long exposure to more addictive medication. But, are we developing adequate and necessary impediments against the risks of poly-drug abuse, suicide and psychiatric illness?
Overdose death issues are so multi-dimensional that coalitions/campaigns are needed consisting of federal, state, and city governments, as seen recently in Dayton, Ohio, which saw a drop in overdose deaths by 50% in 2017, and has been reported in the New York Times. Who should be involved: the CDC, physicians, psychologists, psychiatrists, pharmacists, pharmaceutical companies, poison control centers, forensic pathologists, medical examiners, journalists, first responders, police departments, allied health personnel as nurses, mental health clinics, pastoral care, paramedics, ambulance technicians, mental health professionals, community leaders and organizations? Education about the risks and fatality of drug overdoses is essential at an early age in the home, schools (kindergarten through college), day care centers, mental health clinics, and clubs. Internet providers (as Google, Yahoo, Bing), film and television production companies (Hollywood, Independents PBS, Netflix), and social media (Facebook, Twitter, Snap Chat, Instagram) can provide the images of how to recognize and avoid the toxins, and expound on the deadly consequences. News media, such as the major outlets and cable news, uniting in a joined efforts from all the different viewpoints, reaching the general population with authentic information and viable solutions, is critical. The Veterans Administration is initiating registration and close follow-up for veterans at risk for suicide. The establishment of state health department registries with documentation of overdose attempts and deaths, outcomes and follow-up through mandatory reporting (as currently required for sexually transmitted diseases, trauma, burn) is essential. Also, as noted in Ohio, more access to free medical and mental health treatment once issues arise is mandatory. If “it takes a village to raise a child,” (African proverb), it will take a nation united to cut off dividends for the Grim Reaper.