By Brian N. Talleur, M.D., Chief Medical Officer, Aegis Treatment Centers in California
It’s not easy to find good news in the press these days. It seems like every time we scroll through our media feeds all we see is problems. Take the pandemic, for instance: as the omicron wave subsides across the country – bringing another possible end to this difficult two-year period – now all we see are tragic stories about war in Ukraine.
When we set that aside, we have to recognize that the news about the opioid pandemic has not been a bright spot, either. While awareness about mental health and addiction issues is on the rise – one outcome of the pandemic we didn’t anticipate – overdose rates have increased across the board. From 2020 to 2021, they increased for opioids and for all drugs.
Here are the latest opioid overdose numbers. These are opioid overdose fatalities:
- 2019: 50,178
- 2020: 69,061
- 2021: 73,453
And here are the overdose fatalities for all drugs:
- 2019: 67,697
- 2020: 78,056
- 2021: 100,306
This data has been particularly disheartening for professionals working in addiction and recovery. The progress we made between 2017 and 2019 addressing the opioid crisis is in danger of being eclipsed by the secondary effects of the Coronavirus pandemic. Namely, the fact that stress, isolation, reduced access to treatment, and uncertainty all increase chances of increased opioid use or relapse to opioid use.
However, a report released in mid-2020 showed one program made a difference in a key metric known to be one of the root causes of the opioid epidemic: over-prescribing of opioids to manage post-operative pain. That was a small ray of hope in a relatively grim period. Now – within the context of increasing overdose deaths for opioids and all drugs – there’s another ray of hope: prescriptions for opioids continued to decrease from 2019 to 2021.
First, we’ll talk about the program that led to an overall reduction in prescription between 2018 and 2019.
The Initiative: Educate Physicians to Reduce Opioid Prescriptions
Data from the CDC show that receiving a prescription for opioids that lasts longer than five days creates risk for opioid misuse and opioid use disorder (OUD). This data connects the initiation of opioid use to pain management after short-term elective surgeries. It indicates that long-term opioid use is often the result of dependence that develops unintentionally while in recovery from surgery. We note that in some cases, opioids are effective in the management of long-term, chronic pain – and we reiterate the CDC guidelines that dictate that any decision about pain management should be made between the prescribing physician and the patient, rather than based on an arbitrary set of rules applied in a one-size-fits-all manner.
With that said, the data clearly suggest that a contributing factor to the opioid crisis was the over-prescribing of opioid pain relievers to manage pain that could have been managed with a short course of opioids followed by different pain relievers that carry little to no risk of addiction or disorder use.
This knowledge led to a large-scale effort by Baylor Scott & White Hospitals (BSW) in central Texas to reduce opioid over-prescribing in their clinical network. The BSW includes 15 hospitals, 104 hospitals, and over 1500 physicians. The initiative involved taking advantage of “surgical grand rounds” to inform physicians about the connection between opioid prescribing practices and the risk of opioid use disorder, and to establish a standard of limiting opioid prescriptions to five days or less after elective surgery. After the educational workshops, the hospital system used its electronic records system to monitor and reward physicians for reducing the amount of opioid prescriptions.
The Results: Dramatic Reduction in Long-Term Prescriptions
The initiative and the study on the initiative lasted from January 2018 to March 2019 and involved over 30,000 patients who underwent elective surgery in the BSW hospital and clinic network. Here are the results of the effort, as reported in the study:
- Prescriptions for opioids lasting longer than five days dropped from 1,228 in the three months prior to the program to 432 in the first quarter of 2019.
- That’s a decrease of 64%
- Prescriptions lasting less than five days increased from 5,133 to 5,923.
- That’s an increase of 15%
Dr. Richard Frazee, quoted in Science Daily, reported that getting surgeons to change their prescribing patterns was challenging:
“To change surgeons’ behavior, you have to convince them that it is a benefit to their patients. We had to overcome many years of misinformation on the ‘safety’ of liberal use of opioids after surgery…this program offers a model for other health-care systems and individual surgeons to adopt in the care of their patients”
This effort was a positive step in reversing the practice of opioid over-prescription and addressing its relationship to long-term opioid use and OUD. Now, two years later, new data published by the Centers for Disease Control (CDC) indicates that opioid prescription rates continued to drop across the nation –not just in Texas.
Here’s the data:
Opioid Prescriptions: 2016-2020
- 2016: 214,881,662
- 2017: 191,909,384
- 2018: 168,158,611
- 2019: 153,260,450
- 2020: 142,816,781
That’s good news.
Or rather, it should be good news.
Unfortunately, a report from the American Medical Association (AMA) this year – The 2021 Overdose Report – reminds us that we have to keep our eye on the big picture. What that means is that while opioid prescription rates fell, overall drug overdose and opioid overdose fatalities both increased over the same period, with one exception: a 4.1 percent decrease in opioid overdose deaths between 2017 and 2018.
New Recommendations from the American Medical Association
Part of the effort to mitigate the harm caused by the opioid epidemic was reducing opioid prescription practices, in part based on guidance released by the CDC.
For a complete analysis of the results of that CDC guidance, please read our article The Politics of Addiction by Pinnacle CEO Joe Pritchard.
One component of the effort to reduce prescriptions was the implementation of prescription drug monitoring programs across the country
Here’s the latest data on PDMPs and other harm reduction measures introduced over the past several years:
- Between 2014 and 2020, physician use of PDMPs increased by 1,382%
- Since 2016, the number of physicians certified to prescribe buprenorphine – the medication considered a gold-standard evidence-based treatment of opioid use disorder – increased by 70,000.
- However, prescriptions for buprenorphine have increased only marginally
- Between 2017–2020, community organizations and harm reduction advocates distributed 3.7 million doses of naloxone (Narcan)
- Naloxone prescription from pharmacies decreased 26% during the pandemic
Despite these advances in decreasing rates of long-term prescriptions of opioids and enhancing harm-reduction practices, the rate of drug related overdose fatalities continues to rise, as shown in the statistic cited in the first section of this article.
Most experts believe the stress and other collateral effects of the pandemic overwhelmed the progress made by these programs. To get the response to the opioid crisis back on track – meaning reversing the upward trend in overdose deaths – the AMA released a new set of recommendations.
Here’s what they think we need to do, moving forward.
AMA Recommendations: Opioid Crisis
- Advocate for all states to enact telehealth flexibility that allows for MAT patients to initiate buprenorphine treatment at home
- Decriminalize drug checking supplies. Drug checking supplies are chemicals used to confirm or rule out the presence of deadly additives to illicit drugs, such as fentanyl in cocaine, methamphetamine, or heroin
- Monitor the use of federally distributed opioid litigation funds to ensure they’re used only for the purposes of public health initiatives directly related to the opioid crisis
- Encourage the CDC to amend its 2016 opioid prescription guidance in order to provide compassionate care for patients in extreme pain
- Address longstanding inequities in health care – including addiction treatment, mental health treatment, and general medical care – in communities that have traditionally been marginalized, and for people for whom the social determinants of health have resulted in a lack of appropriate care at all levels
The AMA asserts that a coordinated effort on the part of public health officials, medical professionals, policy makers, state and local officials, and leaders of faith organizations can help destigmatize substance use disorders (SUD) and the treatment of substance use disorders. They know this is possible because that’s what we did before the coronavirus pandemic arrived and turned our entire society upside down – including reversing the progress we’d made in decreasing opioid overdose deaths.
Next Steps: Double-Down on Collaboration, Compassionate Care, and Awareness
We’ll end this article with a quote from the President of the AMA, Dr. Gerald Harmon:
“To make meaningful progress towards ending this epidemic, a broad-based public health approach is required. This approach must balance patients’ needs for comprehensive pain management services, including access to non-opioid pain care as well as opioid analgesics when clinically appropriate, with efforts to promote appropriate prescribing, reduce diversion and misuse, promote an understanding that substance use disorders are chronic conditions that respond well to evidence-based treatment, and expand access to treatment for individuals with substance use disorders.”
This statement says all the right things. We need all these things in place in order to make progress. Perhaps the most important point is the last, because it addresses the culture of stigma around addiction. When we realize, collectively, that SUD – including opioid use disorder (OUD) – is a chronic medical condition that responds well to evidence-based treatment, we can convince everyone who needs help to step forward and ask for that help – without fear of judgment, but rather, with the expectation of acceptance, support, and understanding.