Opioid epidemic ’20: Crisis update, and steps for providers

Most of us are acutely aware of our country’s ongoing opioid epidemic. We read or hear about it — and providers deal with it — virtually every day.

No wonder. Overdose deaths continue to reach new all-time highs (no pun intended), with the Centers for Disease Control and Prevention (CDC) now reporting that 130 Americans are dying each day due to opioid overdoses, many involving prescriptions.

We’ve seen some positive impact, at least in a 20% to 30% reduction in opioid prescriptions. But much work remains to better address the continued epidemic.

Overdoses and deaths are virtually everywhere

Based on the most-recent CDC data, the opioid overdose mortality is:

• Causing more than twice as many deaths in men than women
• Highest among ages 25-34, followed by the next 3 age groups
• Rising with 65+ population, as Baby Boomers hit retirement and people are living longer
• Highest among white non-Hispanics followed by black non-Hispanics and then Hispanics
• Highest in the South, followed by the Midwest, Northeast and then West census regions

For more, the 2018 National Survey on Drug Use and Health (NSDUH) is a valuable statistical and trending resource.

Looking at the bulleted copy above and the CDC report, it’s obvious this isn’t a problem for one city, rural area, state or region. This is an American problem.

Scripts decline, but epidemic remains

Opioids have been broadly embraced by the U.S. population, understandably but unfortunately. Though some have been around a while, opioids such as oxycodone were broadly introduced — and heavily marketed — in the mid-’90s, touted as a better alternative to drugs like morphine and heroin.

It took awhile for the effects of oxy and certain other opioids to show up after the initial hype. But patient access to fentanyl, frankly, should have been more tightly regulated or banned from prescription form from the get-go. Introduced in the ’60s as a legal intravenous anesthetic, you recall it was later allowed to be legally prescribed as patches or lozenges. With its effects about 100 times more potent than morphine and 50 more powerful than heroin, both licit and illicit fentanyl have markedly increased opioid deaths due to its overuse and misuse.

As more data has come to light, there has been a decrease in both the number of opioid prescriptions written, as well as a decrease in the total amount — both dose and quantity — of opioids prescribed since 2010-11. A recent study published in JAMA showed a 20.1% decrease in opioid prescriptions from 2015 to 2017; another CDC surveillance report (page 8, Executive Summary) puts the decline as great as 29% between 2006 and 2018. But it’s still triple the amount prescribed in 1999…and prescription opioids still accounted for 40% of opioid-related overdose deaths in 2016.

The continued supply of opioids, legal and illegal, now contributes to more drug overdose deaths in the U.S. than traffic accidents, gun violence or falls. That’s way too much.

5 steps providers can take

1. Know the pertinent regulations in your state — First, of course, know the increasingly stringent laws for prescribing opioids in your state, as well as pertinent federal and individual insurance policy guidelines that impact your decision-making.Hopefully they’re already part of the clinical decision support offered within your electronic health record, or offered through a medication-management partner like RxLive.But along with other resource links in this blog, here’s the CDC’s Guideline for Prescribing Opioids for Chronic Pain (U.S.) .If you’re not doing so already, monitor your care team’s prescribing patterns not only for each patient but across your patient population. That’ll help you remain mindful of history and trends.
2. Leverage non-opioid treatment alternatives — So much of what I’m recommending in this blog shouldn’t really need to be said. But as part of a checklist, recommend non-opioid medications whenever possible. Often acetaminophen or an NSAID is an appropriate first step; they’re effective for many patients without liver or kidney concerns, respectively.Measures involving non-pharmacologic treatments can be more effective in both the short- and long-term, with even lower risk. These include physical therapy, massage and mind-body techniques (meditation, hypnosis, yoga, cognitive behavioral therapy, etc.). Have an advocate help patients explore what options may be partially or fully covered by their insurance as preventive services. Whenever possible, keep abreast of trustworthy community programs you can encourage your patients to consider. There are often plenty of options at little to no out-of-pocket costs, and patients are often curious but uneducated about non-opioid options they can receive…and afford.
3. Address the underlying disease state while empowering patients — For those persons on unavoidable chronic, long-term opioid therapy, as providers we need to address their underlying disease state, the efficacy of their treatment, and your long-term plan for each of them.
4. Help patients be prepared. Be more proactive in prescribing the opioid antagonist naloxone (such as the brand drug Narcan), easily administered via sprays or auto-injectors. This helps potentially at-risk patients and their loved ones be prepared to administer emergency treatment should the need quickly arise.Naloxone has no effect in persons who aren’t taking opioids, is very affordable with a prescription, and is as low as $21 as a generic (more $ for a brand such as Narcan) based on GoodRx coupon pricing at the time of this post. At such a low price for a potentially urgent, life-saving drug, encourage possible at-risk patients and their loved ones to keep naloxone readily on hand in a purse, car glove box and the many other places where it would be immediately available.
5. PDMPs and other resources for safer opioid use — A number of entities have put together guidelines and resources to assist in the process of safer opioid usage. The American Pharmacists Association (APhA) has a good page under its Opioid Resource Center to link to training and content for healthcare professionals, and here’s the recommendations from the American Medical Association Opioid Task Force for physicians and a link to share with policymakers. As a bonus, you can receive credit for completing CDC training on opioid safe prescribing practices for CMS’ Quality Payment Programs.

Note that the AMA recommends using your state’s Prescription Drug Monitoring Program (PDMP). State PDMPs were used more than 460 million times in 2018 alone. Use the link above to find your state’s PDMP to register and help you make the best-informed prescribing decisions.

We’re here to help

The RxLive team of experienced clinical pharmacists is here to answer any medication-management questions and provide recommendations to our provider partners and to any concerned patients who contact us directly for a comprehensive medication-management consult.

Opening up the dialogue on existing or potential opioid dependency is just the first step. But it’s a good one to help deal with what is a huge issue in our country, and potentially to you and yours.