ATrain Education

 

Continuing Education for Health Professionals

Opioid Epidemic: How Did We Get Here and Where Do We Go Now?

Module 1

Opioid Epidemic a National Emergency

 

Thirty years ago, I attended medical school in New York. In the key lecture on pain management, the professor told us confidently that patients who received prescription narcotics for pain would not become addicted.

 

While pain management remains an essential patient right, a generation of healthcare professionals, patients, and families have learned the hard way how deeply misguided that assertion was. Narcotics—both illegal and legal—are dangerous drugs that can destroy lives and communities.

 

Thomas Frieden, MD, February 24, 2012
Former Director, CDC (Special to CNN)

The opioid epidemic is a problem the likes of which we have never seen.

President Donald Trump
CNN Politics, August 9, 2017

 

On March 29, 2017 President Donald Trump ordered the establishment of the Commission on Combating Drug Addiction and the Opioid Crisis, to be headed by New Jersey Governor Chris Christie. The final report was issued on November 1, 2017. Following is a summary of its recommendations.

Federal Funding and Programs

  1. The Commission urges Congress and the Administration to block grant federal funding for opioid-related and SUD-related activities to the states, where the battle is happening every day. There are multiple federal agencies and multiple grants within those agencies that cause states a significant administrative burden from an application and reporting perspective. Creating uniform block grants would allow more resources to be spent on administering life-saving programs. This was a request to the Commission by nearly every Governor, regardless of party, across the country.
  2. The Commission believes that ONDCP must establish a coordinated system for tracking all federally-funded initiatives, through support from HHS and DOJ. If we are to invest in combating this epidemic, we must invest in only those programs that achieve quantifiable goals and metrics. We are operating blindly today; ONDCP must establish a system of tracking and accountability.
  3. To achieve accountability in federal programs, the Commission recommends that ONDCP review is a component of every federal program and that necessary funding is provided for implementation. Cooperation by federal agencies and the states must be mandated.

Opioid Addiction Prevention

  1. The Commission recommends that Department of Education (DOE) collaborate with states on student assessment programs such as Screening, Brief Intervention and Referral to Treatment (SBIRT). SBIRT is a program that uses a screening tool by trained staff to identify at-risk youth who may need treatment. This should be deployed for adolescents in middle school, high school and college levels. This is a significant prevention tool.
  2. The Commission recommends the Administration fund and collaborate with private sector and non-profit partners to design and implement a wide-reaching, national multi-platform media campaign addressing the hazards of substance use, the danger of opioids, and stigma. A similar mass media/educational campaign was launched during the AIDs public health crisis.
Prescribing Guidelines, Regulations, Education
  1. recommends that HHS, DOJ/DEA, ONDCP, and pharmacy The Commission recommends HHS, the Department of Labor (DOL), VA/DOD, FDA, and ONDCP work with stakeholders to develop model statutes, regulations, and policies that ensure informed patient consent prior to an opioid prescription for chronic pain. Patients need to understand the risks, benefits and alternatives to taking opioids. This is not the standard today.
  2. The Commission recommends that HHS coordinate the development of a national curriculum and standard of care for opioid prescribers. An updated set of guidelines for prescription pain medications should be established by an expert committee composed of various specialty
  3. The Commission recommends that federal agencies work to collect participation data. Data on prescribing patterns should be matched with participation in continuing medical education data to determine program effectiveness and such analytics shared with clinicians and stakeholders such as state licensing boards.
  4. The Commission recommends that the Administration develop a model training program to be disseminated to all levels of medical education (including all prescribers) on screening for substance use and mental health status to identify at risk patients.
  5. 10.The Commission recommends the Administration work with Congress to amend the Controlled Substances Act to allow the DEA to require that all prescribers desiring to be relicensed to prescribe opioids show participation in an approved continuing medical education program on opioid prescribing.
  6. The Commission associations train pharmacists on best practices to evaluate legitimacy of opioid prescriptions, and not penalize pharmacists for denying inappropriate prescriptions.

For the complete report, click here.

 

chart: comparison of drug related deaths in Europe and US

Kristoff N. (2017). How to Win a War on Drugs. September 24, 2017, NY Times.

 

* * *

Bob, a 45-year-old construction worker was being treated in an acute care hospital for a broken femur repair and a low back work-related injury. The nurses offered narcotic analgesics around the clock, as ordered, to keep Bob comfortable. (Rather than offer any other comfort measures, it was just easier to draw up the narcotic to keep him from using the call light repeatedly.)

After he was discharged, Bob followed up with his primary care physician, who initially prescribed oxycodone and muscle relaxers in a limited supply and without refills per standard practice. Within one month, Bob returned complaining of constant pain, and he was given a new prescription for oxycodone. The monthly visits became routine and without additional assessments, offering alternative modalities or a narcotic use contract, the prescriptions continued to be written and filled.

The medications began to offer no further pain relief and Bob began supplementing with legal marijuana to provide relief of the initial back pain and the progressive physical craving for the opioid. He visited several other physicians to increase his supply and none of the providers were aware of his multiple visits and duplicated prescriptions.

Bob eventually advanced to street heroin and ultimately overdosed on the combination of opioids, which took his life.

What could have been done to avoid this needless loss of life?

What is the role of healthcare professionals in the prescribing and monitoring of opioid drugs?

What is the nurse’s role in the opioid epidemic?

What prevention and treatment strategies are available?

Not every opioid-related death is a stereotypical drug addict who is homeless and helpless. Opioid users include persons of any age, gender, religion, or culture who may have been prescribed opioids for pain control of injuries not their own fault. Often the desire for acute or chronic pain relief evolves to the need for stronger pain control and drug seeking behaviors driven by the basic desire for pain relief.

Unfortunately, opioid drug users also include those looking for entertainment through narcotic drug use and those who gradually become addicted. For example, compare these two users: one a teen looking for peer acceptance and entertainment and the other an educated healthcare professional seeking pain relief, and both have serous consequences from misuse of the powerful class of drugs known as opioids.

A 15-year old female overdosed at a high school party after being given street heroin laced with contaminants.

A 45-year old ER physician was caught writing her own prescriptions for oxycodone after suffering from chronic knee pain. Her licensed was suspended and she was then forced into rehabilitation under the terms of the medical board.

Healthcare professionals who are a part of prescribing or administering opioids need to be aware of the potential for abuse and misuse. Not only do they need to be well informed about the appropriate use and cautions for opioid use, but they need to be able to recognize its effectiveness, side effects, and overdose symptoms, and to recognize abuse in patients as well as their colleagues. Healthcare professionals are actually at greater risk than the general population for opioid abuse because of their access to the drugs.

What Are Opioids?

Opioids include codeine, fentanyl, hydrocodone, meperiden, hydromorphone, methadone, morphine, oxycodone, and heroin. Drugs from the opioids class are powerful analgesics and are used for pain management. Because they are powerful, and powerfully addicting, millions of people who use them can become physically and psychologically dependent or addicted to them. From 2000 to 2015, more than half a million people in the United States alone died from opioid drug overdoses.

Opioids are categorized as schedule 1 or 2 drugs by the Drug Enforcement Agency (DEA). A schedule 2 drug such as morphine means that, although it has been approved for medical treatment as an analgesic, it has high potential for strong psychological and physiologic dependence. It has been used for over one hundred years as an analgesic. Heroin is made by taking morphine, which is from the opium plant, and adding a chemical reagent that makes it more potent and potentially dangerous. Heroin is a schedule 1 drug and is not approved for any medical use because it is highly addictive.

Brief History of Opioids

So how did we get to this point of millions of Americans using and abusing opioids? The documented use of opioids began as early as 3400 B.C. in Mesopotamia, where they called it the “joy plant.” Opium was used for every medical malady including diarrhea, cholera, rheumatism, fatigue, and even diabetes by early Egyptians. Opium was regularly traded by the Turks and Arabs in the sixth century.

Opium Poppy Plant

image: opium poppy plant with flower

Source: Wikimedia Commons.

Opioid use became much more common in the early 1700s, when the British refined production from the Asian poppy plant that was grown during the British Crown Rule of India and sold in China. What became helpful as analgesia quickly became popular for treating every possible malady, and was even used as entertainment according to historical records of opium parties (Britannica, 2017).

British ships delivered 1,000 chests of opium into China in the 1760s and gradually increasing it to 4,000 chests in 1800, to eventually 40,000 chests in 1838. Opium was immensely popular in China and the desire for porcelain, silk, and tea was equally in demand in the West, so the trading continued. Alarmed by its powerful addicting properties to the Chinese citizens, the Chinese emperor Yongzheng (1722–1735) eventually prohibited the sale and smoking of opium, which led to opium wars with the Westerners (Britannica, 2017).

Opium trading eventually became more regulated and slowed during the communist reign in twentieth century China. Unfortunately, opium trading continued with new players, notably tropical growers and illegal importers from Central and South America to the United States. In the late 1800s, Bayer manufacturer created and sold heroin, and its misuse was rampant until regulations and taxes were designed to thwart its use. Then, after WWII and Vietnam, another wave of use and abuse crossed America with the resultant reflex to further regulate and tax its use (Britannica, 2017). The war on drugs has continued.

Pain as the Fifth Vital Sign

Concurrent with the increasing demand for opioids here in the United States was the medical profession’s increased interest in addressing patients’ pain. Pain was added as the 5th vital sign in 1996 and a movement to minimize all pain increased prescriptions for opioids.

Campaigns by pharmaceutical companies boasting the effectiveness of their drugs without side effects and added to the growth of prescriptions for opiates. These companies even created organizations with persuasive lobbyists to decrease barriers and regulations on opiate use. In 2007 the maker of Oxycontin (Purdue Pharma) was forced to pay over $6 million in fines for misleading claims about opioid safety.

Another cause for the increase in the opioid epidemic is the ease of creating the drugs chemically, including semisynthetic and fully synthetic drugs created in a laboratory by pharmaceutical companies. Creating heroin from morphine can be done in a home laboratory, thus contributing to the availability of street drugs. The demand for heroin by Americans continues to support the supply coming illegally from Central and South America into the United States.

 

Answer: B

Test Your Knowledge

Which of the following is a cause of the opioid epidemic?

  1. Artificial limitations to prescriptions
  2. Emphasis on treating pain aggressively
  3. Lack of self-discipline
  4. Belief that pain should be treated at all cost

Apply Your Knowledge

Did You Know . . .

Opium comes from the natural Asian poppy plant and is 10 times as potent as cocaine. Heroin (diamorphine) is 3 to 10 times as potent as opium or morphine. Heroin is illegally combined with a chemical reagent called acetic anhydride and often with other often-lethal contaminants to act as stabilizers.

Online Resources

YouTube: American Epidemic: The Nation’s Struggle with Opioid Addiction

https://www.youtube.com/watch?v=nNj89ohoYQ0

YouTube: Inside the Worst Drug-Induced Epidemic in U.S. History

https://www.youtube.com/watch?v=wtnuK1RysGc&t=3s

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