Neurological

Limiting supply alone is not an answer to the opioid crisis

The current US opioid epidemic control system is not ideal. Policies and guidelines have primarily focused on reducing the prescription and supply of opioids. However, the opioid crisis calls for new approaches to the treatment of prescription opioids, according to a special article published in the journal Anesthesiology.1 In their article, Evan D. Kharasch, J. David Clark, and former US surgeon General Jerome Adams write that Restricting supply is not enough on its own, and discussing their new concept of a prescription opioid ecosystem.

“We need a multi-faceted approach where prescribers, patients, pharmacists, insurance companies, healthcare institutions, lawmakers and regulators all work towards a common goal. You need to understand that current approaches don’t work, ”said study’s lead author Evan D. Kharasch, MD, PHD, editor-in-chief of anesthesiology.

“The opioid paradox is that opioid prescribing in the US has decreased 38% over the past decade, but opioid deaths have increased 300%,” said Dr. Kharash. “We should be aware of this, as it shows us that restricting the prescription alone has not been successful in resolving the epidemic and that other approaches are needed,” said Dr. Kharash.

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Better management of the supply of prescription opioids in home pharmacies is urgently needed. According to the study authors, a multifaceted approach needs to address opioid use, storage, return and harm reduction with a special focus on patients and communities. An integral part of the opioid ecosystem is the pool of unused prescription opioids.

The size of the opioid pool is not only influenced by supply and demand. The authors urge anesthesiologists and surgeons to use patient-specific therapies that provide adequate pain relief after surgery. They recommend multimodal strategies with 2 or more drugs or techniques that work according to different and complementary mechanisms. This could provide better pain relief and allow for smaller opioid prescriptions.

Hundreds of millions of opioid pills are distributed to patients in the US but are unused every year. Most are only kept by patients. Only a few pills are safely stored and only a fraction is disposed of or returned. The authors write that the difficulty of returning prescription opioids contrasts markedly with the ease with which they can be obtained. They believe that regulations from pharmacies supplying opioids should provide instructions for their proper return and disposal. This is preferably done on the label and not as a handout. The addresses and telephone numbers of disposal sites should also be provided to patients. Opioid buybacks are another promising approach.

“Legislators, regulators, insurance companies and pharmacists should work to implement a law passed by Congress in 2016 that allows partial prescription filling to reduce the opioid pool,” said Dr. Kharash. With this approach, when a patient needs the additional care, the prescription can be completed in full with no further questions and no additional cost.

Ronald Hirsch, MD, vice president of the Regulations and Education Group at Physician Advisory Solutions, Elgin, Illinois, said that pain responses in humans have evolved as a protective mechanism and that the benefits of treatment must be weighed against the risks in any medical procedure. “If a patient is told prior to surgery that pain is a natural reaction and will wear off over time and treatment to completely eliminate that pain, even a single pill can lead to a life of addiction, I suspect some will would choose to tolerate pain rather than risk addiction, “said Dr. Deer. “This patient might be in pain but be completely satisfied because he expected it and he knows it will get better over time.”

The prevailing attitude strives for zero pain at all costs. However, sending someone home with 3 opioid tablets can lead to an addicted life. Dr. Hirsch said that this new concept of an opioid ecosystem needs to address the problems that trigger its first use. “Nobody develops an opioid use disorder if they never take their first opioid. What the article lacks is data on that first exposure, ”he said. “We need to start reassessing our perception of pain and setting the right expectations. 0 out of 10 pain for every single person in every single life situation is not a noble goal when half a million opioids are the result. “

Addiction medicine physician Orman Trent Hall, DO, of the Department of Psychology and Behavioral Health at Ohio State University’s Wexner Medical Center in Columbus, said that the guidelines of the U.S. Centers for Disease Control and Prevention for chronic opioid treatment Recommend pain to all clinicians or arrange treatment for opioid use disorder. Access to drugs for opioid use disorder drugs is critical to reducing the risk of fatal overdose, especially as the supply of prescription opioids continues to shrink.

“The relationship between opioid prescribing and overdose is complex, and reducing opioid prescriptions has been associated with a shocking increase in deaths from opioid overdoses in recent years,” said Dr. Hall. “This appears to be the result of illegally manufactured fentanyl, which is intended to meet the unmet demand from the increasingly unavailable opioid analgesics. The opioid ecosystem paradigm holds promise in that it is much broader and more nuanced than previous approaches that have mainly focused on lower prescribing. ”

What happens in the trenches?

James Langgabeer, PhD, professor of emergency medicine and biomedical informatics at UTHealth in Houston and founder of the Houston Emergency Opioid Engagement System, said pain specialists believe that most people become addicted to opioids as a result of surgery or a back injury. However, he does not see that. “A lot of people don’t get their opioids the usual way. The classic story was that I broke my leg and he started taking an opioid and four months later I’m taking it, ”said Dr. Langgabeer.

This particular scenario occurs, but Dr. Langgabeer didn’t say nearly as much as pain specialists, anesthetists, and surgeons think. “What we are seeing in Houston are a lot more deaths and people are getting addicted who have never gone a medical route,” he said. “I would say that around 60% get their opioids outside of the medical system.”

He agrees that merely restricting supply does not appear to work and that greater research and intervention efforts are urgently needed. “If you get people to go through too many tires, they’ll find it elsewhere,” said Langgabeer. “If a patient is addicted to meth, they’ll switch to heroin.”

He said doctors only fool themselves if they believe they can fix the problem simply by following current guidelines and protocols. Much more patient counseling and referrals are required, along with the provision of alternative therapies. Dr. Langgabeer said several helpful tools included physical approaches like a TENS machine. He also recommends yoga and teaches patients to meditate. “Massage therapy can help. We have to look at it holistically, ”he suggested.

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Kharasch ED, Clark JD, Adams JM. Opioids and Public Health: The Prescription Opioid Ecosystem and the Need for Improved Management. Anesthesiology. 2022; 136 (1): 10-30.

This article originally appeared on Clinical Pain Advisor

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