Public Health Initiatives to Combat Opioid Painkiller Addiction in America

The rate of overdose deaths involving opioids nearly quadrupled from 1999 to 2011, when 16,917 Americans died of fatal overdoses in that year alone. Furthermore, opioid use is strongly linked to heroin use and other negative public health outcomes. In 2014, the CDC added opioid overdose prevention to its list of the top five public health challenges.

Although the opioid painkiller crisis is often characterized as a problem of nonmedical abuse, the Annual Review of Public Health maintains that it is an epidemic of addiction. Most negative outcomes from opioid use are due to addiction in medical and nonmedical users.

Given the magnitude of the opioid painkiller addiction epidemic and its implications for public health, action is needed. Public health initiatives must combat this by addressing complex causes and effects.

Causes

A leading cause of opioid painkiller addiction is the increase in prescriptions for painkillers, which include medications like hydrocodone (Vicodin), morphine, oxycodone (OxyContin) and oxymorphone (Opana). Facts from the CDC in 2012 illustrate this trend. Healthcare providers wrote 259 million prescriptions for painkillers, or a bottle of pills for every American adult. “Health issues that cause people pain don’t vary much from place to place,” the CDC states, adding that “health care providers in different parts of the country don’t agree on when to use prescription painkillers and how much to prescribe.” For example, Tennessee had nearly 22 times the number of prescriptions written for oxymorphone compared to Minnesota.

Debate surrounds the extent of this trend. Some call for more restrictions on painkiller prescriptions, Voxnotes, and argue that no strong data supports the use of opioids for long-term, chronic pain as opposed to short-term, acute pain. Others hold that painkillers can be a crucial tool for treating pain. Estimates suggest that 100 million or so Americans suffer from chronic pain, and withholding painkillers from patients with legitimate symptoms would be devastating.

Exacerbating the increase in prescriptions for opioid painkillers is the demand that stems from the nonmedical use and sale of painkillers. Nonmedical use can include taking the medication more often than prescribed or not taking it to treat pain but rather “to get high.” According to the CDC, the sale of painkillers has tripled since 1999. For people ages 12 and older who used painkillers nonmedically, more than half got the drug from a friend or relative for free.

Implications

From 1999 to 2011, the opioid-related overdose death rate nearly quadrupled to 5.4 per 100,000 in 2011 from 1.4 per 100,000 in 1999. Each year, the death rate has increased, although the rate of increase has slowed since 2006.

People who abuse or are dependent on opioid painkillers are 40 times more likely to abuse or be dependent on heroin. Four out of five heroin users report that their opioid use began with opioid painkillers, a study from the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality found. In an analysis of heroin users from the Journal of the American Medical Association Psychiatry, “nearly everyone (94 percent) indicated that they used heroin because prescription opioids were far more expensive and harder to obtain.” For heroin users who began using the drug in the 1960s, 80 percent of respondents’ first opioid abuse was heroin. For more recent heroin users, three-fourths were introduced to opioids through prescription drugs.

Strategies and Solutions

Prescription Drug Monitoring Programs (PDMPs)

Nearly every state has a PDMP, which is a statewide electronic database that collects data on controlled substances dispensed in the state. The program monitors information to help deter or prevent cases of drug abuse or diversion. Healthcare providers and pharmacists have access to patients’ controlled substance prescription history for identification of high-risk patients who would benefit from intervention. “PDMPs continue to be among the most promising state-level interventions to improve painkiller prescribing, inform clinical practice, and protect patients at risk,” the CDC says.

“Pill Mill” Legislation

A pill mill refers to a doctor, clinic or pharmacy that prescribes or dispenses drugs inappropriately or for nonmedical reasons. Along with PDMPs, states are enacting pill mill laws to reduce prescription drug abuse or diversion. However, few states have pill mill laws to date. Perhaps the most notable example is Florida, which claims the following results from its pill mill laws in 2011.

• The number of registered pain management clinics dropped to 367 in January 2014 from 900 in 2010.
• In 2011, the U.S. Drug Enforcement Administration (DEA) identified that 98 of the top 100 oxycodone dispensing physicians resided in Florida. Now, none of the top dispensing physicians reside in Florida.
• After seven consecutive years of increases in the number of prescription drug overdose deaths in Florida, figures decreased in 2011 and 2012.

Florida’s PDMP and pill mill laws have resulted in modest decreases in opioid prescribing and use, according to the Journal of the American Medical Association Internal Medicine. In one year, prescriptions decreased by 1.4 percent. The study called for further research on the policies and noted the benefit of studying PDMP and pill mill laws separately.

Improving Legislation and Medical Practice in Prescribing Opioids

Most medical students receive on average 11 hours of training on pain education, and most medical schools do not offer specific training on opioids, substance use disorders or clinical decision-making, according to the 2014 National Drug Control Strategy. The Obama administration has pushed for legislation to require prescribers to receive training on responsible opioid prescribing practices as a precondition of DEA registration. Several states have passed this legislation, including Iowa, Kentucky, Massachusetts, Ohio, Tennessee and Utah. Federal health agencies and departments are implementing similar education requirements for health personnel. Also, the Food and Drug Administration (FDA) is requiring manufacturers of extended-release and long-acting opioid painkillers to sponsor educational programs for prescribers.

Meanwhile, debate continues over whether opioid painkillers should be considered safe. “Unfortunately, some of these educational programs, including those required by the FDA, imply that OPRs [opioid painkillers] are safe and effective for chronic non-cancer pain instead of offering prescribers accurate information about OPR risk and benefits,” the Annual Review of Public Health said.

Secondary and Tertiary Prevention Measures

Secondary prevention refers to screening for a disease or injury that has already occurred, but before serious complications develop. Healthcare providers may encounter early identification opportunities for opioid addiction, such as patients who present for early refills. Also, state PDMPs should be consulted to uncover any attempts to receive opioid painkiller prescriptions from multiple prescribers. “Doctor shopping,” or obtaining prescriptions from multiple clinicians, is common for opioid-addicted individuals.

Tertiary prevention consists of therapeutic and rehabilitative measures once an illness or injury is firmly established. For opioid addiction, the goal is to prevent overdose deaths, medical complications, psychosocial deterioration, transition to injection drug use and injection-related infectious diseases. Measures need to be taken to fulfill the largely unmet need for opioid addiction treatment, according to The New England Journal of Medicine.

Battling Opioid Addiction

Greater awareness, education and resources are necessary to battle the opioid painkiller crisis. Public health professionals can play a leading role in fighting opioid painkiller abuse and addiction. At Rivier University, the online Master of Public Health program provides students with the skills and knowledge to improve the lives of others. The program takes place in a convenient online environment that allows students to maintain their personal and professional schedules.