20 Mar Over half of the 41,502 drug overdose deaths in the U.S. in 2012 were due to prescription drugs, and 72 percent of these were related to opioid painkillers like OxyContin and Vicodin. In 2012, there were 259 million prescriptions written for painkillers in the U.S., enough for every single adult in the country to have a bottle of pills. The problem has been called an epidemic, and there have been a multitude of solutions suggested to reduce the notable death toll. According to Steven Passik, PhD, much of the issue comes down to a lack of consideration of the risks before a prescription is written, and if doctors take more care over prescriptions for those most at risk, the number of overdoses could be drastically reduced. Dr. Passik’s Story: Prescription Painkillers for Surgery Pain Dr. Passik himself received prescription opioids earlier this year after an unfortunate slip on ice. He had to have rotator cuff surgery, and his doctor prescribed him some opioids for the pain. According to Dr. Passik, “They didn’t ask me who I am or what I do. They didn’t ask me a single question about my risk for opioid abuse.” Dr. Passik argues that his doctor was clearly attempting to take the humane approach, aggressively treating his pain to minimize his discomfort. However, Dr. Passik points out, “the pain goes on for 2 to 3 months, and 2 to 3 months is not a trivial exposure in people with risk factors. There’s nothing humane about giving out opioids without necessarily understanding what risk you’re exposing a person to.” He continues, “The point is, what happened to me is not the exception — it’s the rule.” Risk Assessments Before Opioid Prescriptions Dr. Passik’s story is repeating itself across the country, and he sees it as the epitome of the problem that’s sweeping the nation. He doesn’t question the need to prescribe opioid painkillers, but physicians do need to think about the risks for each individual before going straight for the prescription pad. He suggests considering known risk factors for drug abuse, such as being younger, being male, having a personal or family history of substance abuse, having psychiatric issues and other things like a history of smoking before issuing a prescription for a dangerous and addictive substance. Knowledge of these and other relevant psychological risk factors would enable physicians to implement a treatment program that keeps patients safe. This may not be easy, though. Dr. Passik uses the example of a 22-year-old with a drinking problem and a little old lady with arthritis. While the 22-year-old is obviously a high risk individual, the little old lady shouldn’t be ignored just because the majority of addictions happen in people under 35 years old — she needs a risk assessment, too. Doctors would have to drop their assumptions and assess any potential risk. He also suggests that doctors should use other tools, such as abuse-deterrent formulations of opioids, prescription drug monitoring programs, safer packaging and new urine drug tests that offer results in just one to two days. The most risky patients could be urine tested at every visit to keep on top of any developing issues. He does acknowledge that doctors are limited for time, though, and suggests that this is a big factor in the problem, “When you introduce opioids into an 8-minute visit once a month with minimal follow-up, which has been the primary care model, it’s a recipe for a public health disaster.” The Example of Project Lazarus Dr. Passik points to Project Lazarus as an example of a community successfully tackling the prescription drug overdose issue without dramatically reducing opioid prescribing. The project involved raising public awareness, assisting with the creation (and maintenance) of community coalitions, educating healthcare providers on appropriate use of opioids and creating overdose prevention programs. After drastically reducing opioid deaths in Wilkes County, North Carolina, the program is being rolled out statewide. Self-Loathing Predicts Prolonged Opioid Use The central factor in Dr. Passik’s proposal is correctly identifying those at increased risk for opioid addiction. Dr. Passik presented his ideas at PAINWeek 2014, and another presentation at the same event offers further insight into the most at-risk patients. Research from Sean Mackey, MD, PhD, president of the American Academy of Pain Medicine, suggests that using opioids before surgery, greater self-estimated risk for addiction and more depressive symptoms are important risk factors to consider when prescribing opioids after surgery. The biggest factor, however, appears to be self-loathing. As Dr. Mackey commented, “The severity of pain and pain duration didn’t predict the use of opioids at all in our models; it was the psychological factors.” Risk Assessment of Opioid Abuse: A Difficult but Worthwhile Task Of course, determining whether someone struggles with self-loathing isn’t exactly easy. As Dr. Passik acknowledged, time constraints are a big problem with implementing substantial risk assessments, particularly psychological ones, prior to prescribing. However, this doesn’t mean that this solution isn’t the right one. Doctors need to remember that offering powerful narcotic painkillers is not a decision that should be made lightly. Even if it’s unrealistic to propose a full psychological assessment prior to any opioid prescription, doctors should be taking as much time as possible to ensure that their proposed treatment doesn’t open patients up to unnecessary risk. It’s humane to relieve patients’ pain, but not if that decision traps them into lifelong addiction. Some things are just worth taking some extra time for.
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