The Opioid Epidemic: Are We Making Any Progress?
Robert E. Van Demark, Jr., MD
SDSMA President

 

Beginning in the early 1990s (with the addition of pain as the fifth vital sign) there has been a dramatic increase in the use of opioids, especially for patients with chronic pain. At first, these drugs were thought to be safe with little chance of addiction. Unfortunately, this was not true. We are all aware of the epidemic associated with opioids. A recent PubMed search for the term “opioid epidemic” generated 897 articles. The statistics are staggering.

In 2016, there were more than 59,000 overdose deaths in the U.S.

In the U.S., drug overdoses are now the leading cause of death under the age of 50. (In 2016, heroin overdose deaths exceeded gun homicide deaths). 1

The death rate for middle age whites in the U.S. is rising while declining in other wealthy countries (France, Germany, Canada, United Kingdom, Australia, Sweden).  At the same time, death rates for the black and Hispanic population are declining in the U.S. 2

Older women have the highest prevalence (9 percent) of long-term opioid use. Concurrent use of sedative-hypnotic drugs and opioids is common in the older female patient and puts them at risk for adverse effects. 3

Representing less than 5 percent of the world’s population, the U.S. consumes over 80 percent of the world’s opioid supply, including 99 percent of the world’s hydrocodone. Our country also consumes nearly two-thirds of the world’s illegal drugs.4  It is estimated that the U.S. consumes 27,400,000 grams of hydrocodone annually. The four countries of Great Britain, France, Germany and Italy consume 3,327 grams of hydrocodone combined. 5

We are not immune to this problem in South Dakota. 2016 South Dakota Prescription Drug Monitoring Program (PDMP) hydrocodone prescription records show the following: 259,700 prescriptions; 17.49 million doses; 3,410,259 days’ supply; Average prescription: 67 tablets.

What Can We Do?

The nontherapeutic use of opioids has reached epidemic proportions and continues to grow every year. The medical community has a moral obligation to improve the health and the well-being of our patients. In orthopedic surgery, we see many patients taking opioids for both acute and chronic conditions. 

Opioid use has been associated with negative clinical outcomes in chronic musculoskeletal problems. 6

A recent study by Menendez, et al.6 highlights the danger of prolonged opioid use. Data from the Nationwide Inpatient Sample was reviewed for 2000-2011. Patient records for common orthopedic procedures (total hip arthroplasty, total knee arthroplasty, total shoulder arthroplasty and spinal fusion) were reviewed. Patients with a preoperative diagnosis of opioid-type dependence or nondependent opioid abuse had an increased odds of hospital mortality (x3.7), increased morbidity (x2.5), and prolonged hospital stay (x2.5).6

Unfortunately, this is a multi-faceted problem with no easy answer. Several authors have called for a culture change in perioperative surgical care.7,8 Instead of waiting for legislation, there are several things that physicians can do to fight the opioid epidemic. They include:

Multimodal pain management – To decrease opioid use, surgeons have started using multimodal pain management techniques for postoperative pain management. This includes the use of continuous plexus and peripheral nerve blocks, local anesthesia infiltration for surgical wounds, and the use of COX-2 type nonsteroidals.9-14

Prescribing habits – The medical profession needs to improve our prescribing habits for opioids. Do the residents of South Dakota really need 17.5 million doses of hydrocodone in one year for a population of 850,000? As surgeons, we are sometimes guilty of prescribing an excess of pain medication. One study of surgical patients found that 72 percent of the prescribed pills were not used.15 In an attempt to improve prescribing opioids, Gawande8 has recommended the following strategies:

1. Preoperative counseling of patients regarding expectations of pain control; pain control to function (e.g., sleep, eat, ambulate) but not to obtain zero pain relief.

2. The use of nonopioid alternatives for minor surgical procedures.

3. The use of the state Prescription Drug Monitoring Program (PDMP) to review a patient’s prescription history.

4. Providing clear disposal instructions for excess medication.

5. Prescribing the “minimum quantity necessary” of pain medication.

Another change in prescribing is the use of electronic prescriptions. This technology would make it easier to write for smaller prescriptions that could be refilled electronically. Although 81 percent of pharmacies are equipped for electronic prescribing and over 90 percent of physicians are using electronic medical records, only 8 percent of physicians are currently e-prescribing.8

PDMP Use

Providers should query the PDMP for a history of a patient’s use of opioids. The South Dakota PDMP web site address is https://southdakota.pmpaware.net/login.

As health care providers, we face a challenge in the face of the tragedy of the opioid epidemic. We need to be part of the solution. This will require a cultural change in our prescribing habits along with education for our patients regarding expectations of pain control.

Books of the Month – The American Spirit by David McCullough and Steering Clear: How to Avoid a Debt Crisis and Secure Our Economic Future by Peter G. Peterson.

References
1. Katz J. Drug deaths in America are rising faster than ever. New York Times.  June 5, 2017.
2. Kolata G. Death rates rising for middle aged White Americans. New York Times. November 2, 2015.
3. Campbell CI, Weisner C, LeResche L, et al. Age and gender trends in long-term opioid analgesic use for noncancer pain. Am J Public Health. 2010;100(12):2541-7. 
4. Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician. 2008;11(2 Suppl):S63-88.
5. Manchikanti L, Helm S, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3 Suppl):ES9-38.
6. Menendez ME, Ring D, Bateman BT. Preoperative opioid misuse is associated with increased morbidity and mortality after elective orthopaedic surgery. Clin Orthop Relat Res. 2015;473(7):2402-12. 
7. Kaafarani HMA, Weil E, Wakeman S, Ring D. The opioid epidemic and new legislation in Massachusetts: time for a culture change in surgery. Ann Surg. 2017;265(4):731-3. 
8. Gawande AA. Itʼs time to adopt electronic prescriptions for opioids. Ann Surg. 2017;265(4):693-4. 
9. Kelly MA. Addressing the opioid epidemic with multimodal pain management. Am J Orthop. 2016;45(7):S6-8.
10. Kelly MA. Current postoperative pain management protocols contribute to the opioid epidemic in the United States. Am J Orthop. 2015;44(10 Suppl):S5-8.
11. White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg. 2002;94(3):577-85. 
12. Sinatra RS, Jahr JS, Reynolds L, et al. Intravenous Acetaminophen for Pain after Major Orthopedic Surgery: An Expanded Analysis. Pain Pract. 2012;12(5):357-365. 
13. Sinatra RS, Torres J, Bustos AM. Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg. 2002;10(2):117-29.
14. Memtsoudis SG. Guest editorial: perioperative pain management in orthopaedic surgery: editorial comment. Clin Orthop Relat Res. 2014;472(5):1375-6. 
15. Hill MV, McMahon ML, Stucke RS, Barth RJ Jr. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017;265(4): 709-14.