Abuse of opioids (narcotic pain relievers) in the U.S. has increased four times over the last decade. Deaths from opioid pain relievers have simultaneously increased at the same rate. While states vary in their statistics, Louisiana ranks among the higher states for use and among the highest for opioid-related deaths. Over 5% of adult Louisianans (over 225,000) engage in non-medical use of opioids, resulting in 15 deaths/100,000 residents (or around 675 deaths per year). Sales of opioids amount to 6.8 kilograms (15lbs.)/10,000 Louisiana residents per year.
The extent of the problem is staggering since deaths are only the tip of the iceberg. For every opioid-related death, there are 32 emergency room visits for overdose, 136 people who are addicted and 825 non-medical opioid users. For Louisiana, this translates into 21,000 ER visits, 92,000 opioid addicts and 555,000 non-medical users (about 12% of the state’s population or the equivalent of the entire population of Jefferson Parish).
With crackdowns on the illegal use of prescription opioids, there has been a corresponding increase in heroin use. Law enforcement personnel have likened this phenomenon to “Whack-a-mole”, where creative addicts and entrepreneurs find alternative sources when one dries up or becomes too expensive. Florida noticed that when Oxycontin diversion (illegal use) decreased, methadone use increased proportionally.
So, where does this torrent of opioids come from? Among users, over half of it is provided free from well-meaning friends and relatives who “share” their pain medications. Doctors prescribe about 18%, while another 16% is stolen or purchased from family members or friends. Drug dealers account for 4% and internet purchased make up another 1%. Risk factors for slipping from legitimate use into abuse are: prior history of substance abuse, underlying psychiatric disorders, younger age (adolescents), and a family history of substance abuse.
Although non-narcotic pain relievers should always be the first treatment option, they can and do fail to relieve some chronic pain. Prescription of narcotics remains a constant challenge to all physicians and their hesitancy must not be construed as a lack of compassion, but rather the wisdom born out of difficult therapeutic experiences with substance abusers.
What should the patient expect with long-term use of extended release or long-acting opioids? First, the physician will expect complete prior medical records from the patient. Second, you will undergo a thorough medical exam, including a urine drug test (which may be repeated periodically). Third, you will fill out an “Opioid Risk Tool” or some other similar document to assess your susceptibility to substance abuse. Fourth, physicians will consult the Prescription Monitoring Program, run by the Louisiana Board of Pharmacy, which tracks all narcotic prescriptions to discover “doctor shopping”.
Goals of therapy will be to: decrease pain, restore function and improve the secondary consequences of pain such as weakness, instability and maladaptive behavior. Before initiation of Extended Release (ER) or Long Acting (LA) Opioids, you will also be expected to fill out a “Patient Prescriber Agreement”—a document explaining risks and benefits and outlying patient policies and expectations. Dosing of ER/LA opioids is complex and requires considerable expertise, especially when changes are made.
Despite all of the precautions, patients may intentionally or unintentionally overdose, resulting in respiratory depression and death. Given the increase in deaths associated with increased heroin use, the FDA has approved a new automatic naloxone injector (Evzio). Naloxone reverses the effect opioids and may prove lifesaving to family members and emergency personnel. The injector can be administered directly through clothing into the lateral aspect (side) of the upper thigh. It is not intended to substitute for an emergency room visit, which should follow any episode for respiratory failure.
Opioids have transformed the lives of chronic pain sufferers, but they must be used appropriately by trained professionals. Unfortunately, opioid use and abuse has multiplied in the last decades and become a problem of catastrophic proportions. Providers and patients should be part of the solution and not part of the problem.