Public Health Implications of the Opioid Crisis

Saul Levin, M.D., MPA

This blog post is part of a weekly series focusing on different aspects of public health leading up to Public Health Thank You Day on Monday, November 21, 2016. Join the conversation on social media with the hashtag #PHTYD and visit www.publichealththankyouday.org for more information. 

Deaths in the United States due to prescription and illicit opioid overdoses have quadrupled over the past 17 years. According to the Centers for Disease Control and Prevention (CDC), 78 Americans die each day from overdoses of drugs like oxycodone, hydrocodone, methadone, and heroin. Over the course of the opioid crisis, sales of prescription opioids in the U.S. have nearly quadrupled, but the amount of pain reported by patients has remained the same.

Highly addictive opioids have become overprescribed, and this has contributed to a significant public health issue. About 100 million American people suffer the agony of chronic pain that may be caused by sports and work injuries, and other illnesses.  But efforts to treat them with more pain relief have left more than 2 million Americans with opioid use disorders.

Addiction has no racial, economic, or geographical bias. It is a chronic and complex brain disease that manifests in compulsive substance abuse despite its harmful effects. Cognitive impairment becomes part of the problem, as does opioid tolerance, which results in the need for larger and larger doses.  We believe this cycle leads to harmful and longstanding changes in how the brain functions. Research shows that when patients fixate on breakthrough pain during treatment, recovery is prolonged. The complex goal, then, is for pain to be managed without long-term use of opioid analgesics.  The recommendations provided in the CDC Guidelines for Prescribing Opioids for Chronic Pain assist physicians in providing their patients safe and effective pain management that will also minimize the risk of addiction and overdose. 

Additional research into evidence-based strategies for treatment and prevention is needed, and it must include the bio-psycho-social perspective. We need to start at the level of biological pathways, move from there to the understanding of pain disorders, and then to effective prevention measures, next moving to levels upstream from prevention, like Congressional legislation for research funding and treatment of substance use disorders.

The National Institute on Drug Abuse (NIDA) has been working to map the brain’s addiction pathways. This research is critical not only to see how addiction works but also to work out how medical treatments can be effective without causing addiction. Psychiatric research involves counseling, psychological understanding, and development of uniform diagnostics and communication strategies. Social research on housing, employment, and nutrition needs to be stressed as well, to look at pain comprehensively and to work with the whole patient.

When a person is in pain, their entire family becomes affected. Medication can seem like an easy solution to everyone involved, but ensuring the best treatment while simultaneously avoiding tolerance and increased opioid use is complex. This requires a clinician who provides evidence-based treatment.

Physicians must be cautious in prescribing opioids. Before prescribing an opioid, the State Prescription Drug Monitoring Program should be accessed to assure that the patient is not already taking opioids prescribed by another clinician. The prescriber must also limit the number and the dosage of the opiates they prescribe.  The medical profession and community groups are trying to work together on this through providing physician and patient educational programs. Government agencies like HHS, FDA, and DEA are providing effective leadership and are promoting evidence-based education and practice. 

At community and society levels, it is important that we destigmatize mental illness and substance abuse to remove the social obstacles to early care access. Early identification, early intervention, and early treatment afford chances to avoid full-blown disease. The more we talk about opioid addiction, the more we can bring it out of the shadows into the light, and the more we can showcase the prevention vehicles available to people at individual and community levels. First responders now carry naloxone, which is used to reverse opioid overdoses and save lives.  When people feel that they have the power to help someone else recover, it gives us a greater chance of successfully addressing this epidemic.

Ultimately, we want our patients’ and our family members’ pain to be under control in a way that doesn’t require ever increasing medication dosages, and we need research to understand this difficult balance. Research will be the answer to the opioid epidemic.

Saul Levin, M.D., MPA, is the CEO and Medical Director of the American Psychiatric Association.

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