According to surveillance data from the Centers for Disease Control and Prevention (CDC), mortality from drug overdose has steadily increased since the dawn of the new millennium. More than 600,000 overdose deaths were reported from 2000 to 2016. According to the CDC, the first wave began with increased prescribing of opioids in the 1990s and then though the pill mills until approximately 2010. The second wave began shortly thereafter with increased overdose deaths involving heroin as the cost of prescription opioids increased when the pill mills were shut down. The third wave began in 2013 with increased overdose deaths involving synthetic opioids – particularly when illicitly manufactured fentanyl was first used as an additive to Mexican heroin. The illicitly manufactured opioid market continues to change, and is still found in combination with heroin, counterfeit “look-alike opioid prescription medication, spiked marijuana, and now cocaine.
In spite of this changing data, legally prescribed opioid use remains the focus of the most recent opioid “epidemic”. To wit, approximately 63% of the 52,404 overdose deaths in 2015 involved an opioid—but which one? By 2016, the trend was clear– heroin and fentanyl killed the majority of the 42,000 people who overdosed in 2016, more than any year on record. Further, 40% of opioid overdose deaths involved a prescription opioid. This does tell us whether the prescription opioid was attained legally or illegally. Pop star Prince died from an overdose of counterfeit oxycodone tablets, spiked with fentanyl.
Although various strategies have been introduced to address the crisis, including implementation of the CDC Guideline for Prescribing Opioids for Chronic Pain , as well as efforts to improve prescription drug monitoring programs and better access to treatment for opioid use disorder.
Figure 1 CDC Clinical Guidelines for Physicians Prescribing Opioids (CDC 2017):
| The CDC Guideline addresses patient-centered clinical practices including conducting thorough assessments, considering all possible treatments, closely monitoring risks, and safely discontinuing opioids. The three main focus areas in the Guideline include: 1. Determining when to initiate or continue opioids for chronic pain
2. Opioid selection, dosage, duration, follow-up, and discontinuation
3. Assessing risk and addressing harms of opioid use
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These recommendations from the CDC are excellent but without adequate training for physicians who deal with chronic pain or addiction on a regular basis, they will likely not produce the change we hope for—and for good reason. The fear of suspicion and retribution from governing bodies who monitor prescription opioids and all scheduled medications have kept physicians from prescribing these drugs for their patients who need them. Many will recall the latter days of the pill mills, with surveillance videos of sketchy looking characters carrying trash bags full of hydrocodone and oxycodone out of a doctor’s office as part of a covert sting operation–followed by the physician in handcuffs being “perp walked” on the nightly news. These images became iconic in the American psyche and have changed medical practice. Yet for the millions of Americans who suffer from legitimate chronic, non-cancer pain, this is a frightening prospect. Why? Because for most pain patients, opioids have provided a viable means to a quality of life.