The Pain Caused by Painkillers: A Health System's Response to the Regional Opioid Crisis

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A Long-Range Approach to a Problem with a Short but Deadly History

She could be your neighbor, coworker, or your child's teacher, and suddenly you see her obituary in the newspaper. The cause of death, however, was neither natural nor accident-related. More and more residents of our region are becoming ensnared in the gnawing trap of opioids – medications that include oxycodone, methadone, hydrocodone, and a powerful synthetic opioid, fentanyl. Record numbers of people are succumbing to overdoses from these drugs, which were once promoted to physicians by pharmaceutical companies as perfectly safe tools for managing chronic pain. For a time, they were prescribed freely, but as addiction and overdose rates soared, it became apparent to clinicians that these were actually highly addictive substances. Rapidly rising rates of misuse, abuse, and tragically, overdoses and overdose deaths have become horrifyingly commonplace across our counties.

No single demographic, it seems, has been spared the scourge of opioid addiction, and there is no typical abuser portrait for the opioid crisis. Those in the grips of opioid addiction are just as often white collar professionals or mothers of small children as they are wayward teens or homeless adults.

The statistics around opioids are chilling. As of 2014, over 2 million people were dependent on or abused prescription opioids. Over 1,000 people per day are treated in Emergency Departments across the country for opioid misuse, and the group at highest risk for opioid addiction is Non-Hispanic Whites between the ages of 25 and 54. Male addicts currently outnumber females, but the gap is closing quickly, and substance experimentation starts early: Over 90% of adults with substance abuse disorders started using before the age of 18. Adolescents are at particularly high risk for developing opioid addiction, not only due to their proclivity to take developmentally typical risks, but because they are experiencing record rates of anxiety and depression nationally. These conditions are typically treated with opiates and benzodiazepines such as Valium. This benzodiazepine-opioid prescription combination significantly increases the risk for misuse and addiction.

The opioid problem is uniquely insidious because these are not illegal drugs that are the stuff of crime dramas or that are far removed from "polite" society. These drugs were, for years, considered safe and legitimate by providers who unwittingly prescribed them. Opioid pain reliever-related overdose deaths are not only rising at a faster rate than deaths from any major cause, they have more than tripled during the period from 2000 to 2015, according to the Centers for Disease Control (CDC), and nearly half of all overdose deaths involve prescription opioids.

How is North Carolina's Opioid Epidemic Impacting the Local Health System?

Sadly, the South outstrips other areas of the country, including the United States as a whole, when it comes to opioid overdose-related deaths. In North Carolina, prescription opioid deaths, many of which are unintentional, numbered just over 100 in 1999, while a mere 16 years later, in 2015, that number climbed to nearly 740. Accordingly, our health system has seen startling opioid-related patient data that reflects this nationwide trend. For example, total opioid, heroin, and methadone poisoning instances surged during the period from October, 2016 through September, 2017, with a peak in February, 2017 and alarming upticks in May and July. In terms of individual patient lives affected, an astonishing 303 overdoses and 12 deaths were recorded during this period. Chronic pain is a concern for fully one third of all the patients who come through the doors of our hospitals.

Additional Health Challenges Posed by Opioids

A true irony that exists regarding opiates is that they have not been proven to be effective for addressing pain. It seems that, in the rush to get them on the market, important research steps to ensure their effectiveness and safety were either downplayed or skipped entirely. These medications have not only flooded the open market, but the black market too; excessive quantities of these pills are often prescribed for patients who undergo surgery, for example, which leads to a surplus of unused pills. These often sit ignored in the bathroom medicine cabinets of many homes, but when a dependent individual is pursuing these drugs, they will often steal and use the "dregs" of legitimately prescribed opioids. The North Carolina STOP Act of 2017 is a legislative effort to address this problem by requiring physicians to prescribe smaller amounts of these drugs at a time for individuals, as well as increasing monitoring and documentation to lessen misuse. This is just one initial step, however, in the expansive arsenal needed to stem the growing dangers posed by opioids.

Another lethal transition the medical community has observed is that large numbers of patients patients have gone from ingesting pills to using IV heroin and fentanyl, two drugs which are much lower in cost than pain pills. IV use of methamphetamines is also on the rise.

Another serious health risk that goes hand in hand with IV drug use is infective endocarditis, an infection of the heart's inner lining and valves which is both life-threatening and expensive to treat – valve replacement and a six-week course of antibiotic treatment is the standard protocol. Hospitals have seen instances of the malady double in just two years, from 2013 to 2015, and the health system treated an average of 16-17 patients for this per day in September and October of 2017.

Behavioral health needs are also at the core of the opioid crisis. The treatment of chronic pain becomes even more complex when a psychiatric diagnosis – and the drugs necessary to treat it – accompanies the condition. In this region, patients, according to the health system's Director of Ambulatory Behavioral Health, "have limited access to high quality MAT (Medication Assisted Treatment) and our primary care providers are challenged with meeting the behavioral needs of these patients." The complications that come along with addiction mean that it's far more than a physical health problem.

Carolyn C
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