How can we combat the opioid epidemic?
One of the government’s most recent suggestions is to take Opana ER, an opioid indicated for very severe pain, off the market. The request, filed by the U.S. Food and Drug Administration in June, was linked to concerns of abuse-related HIV and hepatitis C outbreaks.
But removing access to opioids altogether isn’t the solution. There are individuals suffering from chronic pain who need or strongly benefit from these drugs. The National Center for Health Statistics estimates that a fourth of the nation’s population suffers from pain lasting longer than 24 hours. Millions more suffer from acute pain.
As a researcher who studies how pharmaceuticals are used and what effects they have, I believe it makes more sense to reduce both the supply and demand side of prescription drug abuse — without interfering with their safe and appropriate use. We can do this by reimagining how we design and prescribe addictive drugs.
Redesigning the pill
Opioids such as morphine typically relieve pain by acting on opioid receptors distributed throughout the central nervous system.
The FDA has come up with a number of ways to deter abuse by changing the way drugs work. For example, manufacturers could include an opioid antagonist in the formulation. This is essentially a drug that blocks the opioid’s effect by binding to the same receptors in the brain that the opioid would. Changing the formulation in this way would reduce the chances of experiencing the euphoric high that leads to addiction.
A good example of an opioid that does this is Targiniq ER. If Targiniq ER is crushed or dissolved, it releases Naloxone, an opioid antagonist that blocks the effect of the opioid.
Another option is to redesign the drug so it must be injected or implanted, instead of taken orally. That way, the drug would potentially have to be delivered under medical supervision. Requiring the drugs to be delivered under medical supervision could also potentially reduce the improper use of needles and related outbreaks.
Even so, no method is foolproof; abusers can sometimes manipulate a changed drug. For example, Opana ER was designed to be difficult to crush, but abusers began to dissolve the drug into a solution and injecting it. To deter drug abuse, Opana ER’s manufacturer, Endo Pharmaceuticals, devised a new medication formula that made the coating more difficult to crush or dissolve. Unfortunately, abusers still found a way to remove the coating and inject the drug.
Required prescription monitoring
Prescription drug monitoring programs have shown considerable promise in tracking potential abusers.
These programs provide emergency departments and physicians with information about a patient’s past use of controlled substances at the point of care. This can immediately flag any potential for abuse, making the doctor’s decision to prescribe opioids — or not — much easier.
Now, the U.S. Substance Abuse and Mental Health Services Administration has funded at least nine states to combine their prescription monitoring programs with local hospital electronic health records and other systems already in place. These collaborations provide clinicians with a comprehensive history of controlled substance, so they can make informed decisions about patient health.
This has already had some success. For example, Illinois saw a 22 percent decrease in number of opioid prescriptions issued by prescribers and a 41 percent decrease in the number of patients who received at least one opioid prescription.
More information on the nature of the epidemic — particularly its link to rural areas — could yield clues about where and how to intervene. However, publicly available data have limited geographical information and don’t cover all information we might need, such as data about dose or treatment duration. What data are available are restricted to protect the identity of individuals.
Rather than look at patients with opioid issues, we decided to look at the doctors who prescribe the drugs. Our group has been working with the state of South Carolina to combine our prescription drug monitoring program, called South Carolina Reporting and Identification Prescription Tracking System, or SCRIPTS, with Medicaid data.
While we were able to combine only two years’ worth of data, our research led to important insights into the abuse potential within South Carolina.
By geocoding state prescription information, we found that a relatively small percentage of providers, concentrated in a few counties, accounted for most opioid prescriptions. In 2010, the top 10 percent of prescribers wrote more than half of all opioid prescriptions.
This group represents a potential target for physician education and engagement in handling pain management and appropriate use of opioids.
Rethinking how we assess patients
Many solutions to the opioid crisis tend to focus on how far it has come and how to mitigate it. However, a more sustainable approach would be to rethink the process of care and engage the patient — who is at the center of it all.
When patients are engaged in the care process, they tend to adhere more to their prescribed regimens and experience better health outcomes.
In most primary care settings, it is considered standard practice to ask patients to rate their pain on a scale from one to 10. This is a very crude measure, but now we need a more sophisticated method. Medical care should consider not only the providers’ preferences, but the patient’s, too.
We need a tool that gets at not only the level of pain an individual experiences, but also their preferences in dealing with pain. Studies show that patient-provider communication plays an important role in pain management. If patients could share their specific concerns regarding their pain and their goals for treatment, then clinicians would be able to find the best treatment plan that is tailored to individual patient preferences.
Rather than using a standardized approach that matches pain level to doses of an analgesic or opioid, clinicians should assess each patient individually, looking at their tolerance for pain, their priorities for treatment and how they value outcomes.
By centering pain management on individual patients, we can give them a voice in the decision-making process. Given the issues with opioid abuse, I think such a pain management tool would yield a multitude of benefits, such as cutting down unnecessary prescriptions, matching the therapy to the patient’s needs and improving outcomes.
Zaina Qureshi, Assistant Professor Department of Health Services Policy and Management; Adjunct Professor Department of Clinical Pharmacy and Outcomes Sciences; Principal Investigator William Jennings Bryan Dorn Veterans Affairs Medical Center, University of South Carolina