Turn on your TV or radio and within minutes you will hear that we are in the midst of what has been termed, an “Opioid Epidemic.” Perspective in everything is always important. So, let us look at the definition of an epidemic. From Webster's Dictionary, epidemic is “the rapid spread of infectious disease to a large number of people in a given population within a short period of time, usually 2 weeks or less.” Clearly, this definition does not fit the current environment in the United States. It seems many professional health care groups in America are weighing in. Guidelines, recommendations, ideas, and sometimes sensationalism are flooding the arena. Everyone feels they have an answer to this opioid “crisis.”
The picture that so often is painted via the media is that prescribers are simply overprescribing opioids, and if they stopped overprescribing (i.e., followed Centers for Disease Control and Prevention (CDC) recommendations for less than 90 mg equivalent of morphine per day) that, the issues would quickly remedy. However, that is an oversimplification of a much larger problem (CDC, 2018).
What do we know? Are overdose deaths of opioids at an all-time high? Yes. Yet, “current policy has brought high-dose prescriptions down 41% between 2010 and 2016, another 16.1% in 2017 and another 12% in 2018.” Despite prescriber efforts, spurred from the CDC guidelines, there continues to be a steady increase of opioid overdose deaths annually, up 9.6% in 2017 (Goodnough, 2017). An example, in Illinois, opioid overdoses increased from 589 in 2015 to 1,233 in 2016, despite a significant decrease in opioid prescribing rates in that state. The increase seems to be almost completely driven by illicit fentanyl analogs, not legitimate fentanyl prescribed for the chronic pain patient (Schatman & Zieglar, 2017).
What is always important to ask is… Is the information being reported correct? Are we really seeing the entire picture of the crisis? I do not think we are. The media reports that opioid overdoses have skyrocketed and overzealous, greedy, pharmaceutical companies along with overprescribing health care providers are to blame. It is just not that easy.
Although we would all agree that one preventable death is one too many, perspective is imperative in making an educated decision on the information presented via media. The current statistics report that drug deaths (including ANY drug or medication a patient takes) accounts for 60,000–70,000 annual deaths. Of these, opioids (including heroin, fentanyl, and prescription opioids) are responsible for 30,000–40,000 of those annual deaths. Compare this to the number of annual deaths from hospital—acquired infections at 99,000 annually and all deaths from tobacco, alcohol, guns, and traffic accidents that account for 700,000 deaths annually (CDC, 2018).
The term opioid is often interpreted as being synonymous with a prescribed medication that is obtained from a prescription written by a health care provider. This often shows health care providers in a negligent, negative light. In fact, opioids include both legally prescribed and illegal drugs such as heroin and illicit fentanyl analogs. The number of actual prescription opioid overdose deaths is only a small percentage of the overall opioid overdose statistics. For instance, the CDC reported in 2018 that fentanyl is responsible for 79% of all opioid overdose deaths. Therefore, the first reaction might be “no one should ever prescribe fentanyl.” Yet, the same CDC report noted that only 5% of all fentanyl overdose deaths are due to pharmaceutical grade fentanyl.
What has been clearly observed is the fact that when opioids are taken concurrently with benzodiazepines, opioid overdose does increase whether in conjunction with a prescribe opioid or illicit opioids. A cohort study in North Carolina found that the overdose death rate among patients being prescribed a combination of benzodiazepine and opioid was 10 times higher than among those only being prescribed opioids. National Institute on Drug Abuse reports that between 1996 and 2013, the number of adults who filled a benzodiazepine prescription increased by 67%, from 8.1 to 13.5 million (National Institute on Drug Abuse, 2018). Both prescription opioids and benzodiazepines now carry Food and Drug Administration “Black box” warnings on the label, highlighting the dangers of using these medications together. For this issue, it seems that our biggest issue is not prescription opioids, but mental health access, addiction, and polypharmacy. In New Hampshire, 72% of deaths involving oxycodone also included alcohol and/or benzodiazepines, cocaine, kratom, methamphetamine, and other opioids (which may not have been prescribed concurrently) (Schatman & Zieglar, 2017).
Other discussions involved the consequences of access to prescription opioids among teens and young adults, and the relationship to addiction in adulthood. Although one answer might be to limit opioid prescriptions to all below a certain age regardless of their pain pathology, there is little debate that parents should be responsible for administering opioids to teens, when a procedure or injury requires stronger analgesia. However, the expectation that a young adult taking a prescribed opioid will then become addicted has been oversimplified in the media. The greater risk for addiction, as well as mental health disorders, is linked to adverse childhood trauma. “Data from the most recent National Survey of Adolescents and other studies indicate that one in four children and adolescents in the United States experiences at least one potentially traumatic event before the age of 16.” (NCTSN, 2008) It has been found that many of these young adults develop substance abuse disorder as means of coping with childhood events, and these adults also find it more difficult to stop use of opioids both prescribed or illicit and describe more drug cravings than young adults and adults who have not experienced a traumatic event. Therefore, identifying and treating children and young adults after traumatic events is vital to their well-being into adulthood (NDTSN, 2008).
The problem is multifaceted. Simply reducing the number of opioids written per patient is not changing the fact that overdose deaths are on the rise—despite our best efforts. We cannot oversimplify an issue and expect it to go away. An accidental death from a prescribed opioid, illicit opioid, or any other medication should be prevented whenever possible. The answers are not simple. The present problem is more about illicit drug use along with use of prescription opioids and other sedating medications that are responsible for most “opioid drug deaths.” More deaths are associated with illicit use of prescription opioids, than the intended prescribed reason. It has been estimated that 75% of overdose deaths of a prescribed opioid were as a result of the person taking an opioid not prescribed to them. Many in our society are looking for an escape and finding it dangerously through polypharmacy. The incidence of substance abuse has dramatically increased. It is not being adequately addressed in our nation. It is a medical, legal, and socioeconomic problem that involves unemployment, inadequate education, and limited access to an inadequate mental health care system. It is complicated by mental health stigmas, the availability of illicit drugs, diverted prescription opioids, genetic predisposition to substance abuse, and psychiatric comorbidities.
Where do we go from here? More providers need to screen for substance use disorders and adverse childhood events. States need to allow more nurse practitioners (NPs) and Physician Assistants (PAs) to treat substance use disorder. We need more time during visits in primary care to spend with patients to properly screen for mental health issues. More education is needed on how and when to prescribe opioids and on appropriate alternatives. Nurse practitioners can provide leadership toward solutions by participating with other stakeholders on the local level and state and national levels. Let voices of NPs be heard in committees, at hearings, and through letters to editors and elected officials. Greater awareness and education on a national basis is needed on appropriate disposal of medications when they are no longer needed, to help reduce the likelihood of diversion.
Nurse practitioners are educated to look at the whole person and have a place at the table in finding ways to continue to treat patients in the safest and most effective ways possible. Nurse practitioners are directly involved in the crisis of substance abuse that leads to opioid deaths. Let us look for ways we can all be part of the solution.
Goodnough A. (2017) Opioid
prescriptions fall after 2010 peak, CDC report finds. The New York Times. Retrieved from https://www.nytimes.com/2017/07/06/health/opioid-painkillers-prescriptions-united-states.html
National Institute on Drug Abuse (2018) Benzodiazepines and opioids. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines-opioids
Schatman M. E., Zieglar S. J. (2017). Pain management, prescription opioid
mortality, and the CDC: Is the devil in the data? J Pain Res, 2017, 10, 2489–2495.
The National Child Traumatic Stress Network. (2008). Understanding the links between adolescent trauma and substance abuse, Retrieved from https://www.nctsn.org/sites/default/files/resources/understanding_the_links_between_adolescent_trauma_and_substance_abuse.pdf