When it comes to doctors and the opioid epidemic, we have a great responsibility as prescribers to decrease the use and abuse of opioids with our patients.
According to the Centers for Disease Control and Prevention, in 2018, nearly 70% of drug overdose deaths in the United States involved opioids. That's roughly 47,000 opioid deaths.
As doctors practicing in the midst of the opioid epidemic - and as prescribers of opioids - we need to be part of the solution, not the problem. Doing so requires us to realize that the problem can affect anyone, including our neighbors, our children, our siblings and our parents. And it not only affects the opioid-dependent individual but also their entire family. In fact, "opioid overdose orphans," who have had one or both parents die from an overdose, are becoming more common.
In his lecture "The Clinician's Role in Solving the Opioid Epidemic," now available for CME credit through AudioDigest, trauma surgeon Dr. Andrew Bernard offers practical tips and practice standards to assist doctors in addressing the opioid epidemic.
The impact of prescribing opioids
In his talk, Dr. Bernard describes the life cycle of opioid prescriptions. If you give 100 opioid prescriptions to opioid-naive patients - for example, after an ankle fracture - what happens to them?
- 20 use the prescription appropriately. These patients use the entire prescription and don't ask for refills.
- 40 don't take the entire prescription. Of these, 10 dispose of extra pills properly, while 30 leave the extras somewhere. Those extras are now vulnerable to be taken by others, who could potentially fall into the world of opioid dependence.
- 40 will ask for more. Of those, 28 will use the refill properly, but 12 will get into serious trouble. From there, 10 of those 12 will misuse, becoming dependent or addicted. Next, 1 of the 12 will become a heroin addict and maybe even go into the business. The last 1 of the 12 will die.
This means doctors in the opioid epidemic need to worry about 10% of their patients receiving opioid prescriptions. That's potentially a lot of people to monitor.
Dr. Bernard also reviews a graph comparing the number of pills prescribed and the number of refills given to the number of patients continuing to take opioids one and three years later. The graph shows that the fewer pills and refills given, the less dependent people are in one and three years. In addition, 50% of patients revealed that they only take pain medication for one or two days, or some none at all, after a surgery. The reality is that patients probably don't need as much pain medication as we think. As doctors, we can impact the opioid epidemic by consciously avoiding each additional day of medication supply beyond three days and each refill.
Just as antibiotics are generally effective when used appropriately, the same can be said for opioids. They're effective in managing acute pain, for instance after surgery, but shouldn't be used for chronic pain. If used inappropriately, these drugs can have adverse effects - for antibiotics, bacterial resistance; for opioids, drug abuse, overdose and death.
Doctors and the opioid epidemic: What can we do?
Given this knowledge, clinicians have a critical opportunity to help mitigate the opioid crisis. Dr. Bernard offers several tips to keep in mind when prescribing opioids:
- Only prescribe opioids when necessary. Consider suggesting Tylenol or NSAIDs first.
- Avoid high doses, long duration of use and refills.
- Avoid long-acting opioids (MS Contin, Oxycontin) for acute pain.
- Avoid opioid/benzodiazepine combinations. If a patient is already taking benzodiazepines, consider prescribing NARCAN.
- Use prescription drug monitoring programs to look at data regarding your patient's previous opioid use.
- Provide NARCAN for those patients with a history of opioid abuse or dependence.
- Educate patients about safe disposal.
On a systematic level, too, doctors as a community have the ability to help solve the opioid epidemic. We can start by following prescription guidelines and protocols. We must address abuse or misuse immediately with patients to prevent nascent issues from spiraling out of control. And we should educate our patients, especially those we're most concerned may misuse opioids.
As doctors and prescribers, we can have a meaningful impact on the opioid epidemic. By becoming more conscious of our prescribing practices and how we educate our patients, we can be part of the solution to this national tragedy.