Opioid Abuse and Overdose

Abstract

Prescription drug misuse has reached epidemic proportions in the United States. Given the magnitude of the problem, strategies to prevent initiation of prescription opioid misuse, treat existing opioid use disorders, and prevent overdose are of utmost importance. This article will summarize such strategies, including improved prescriber education, prescription drug monitoring programs, medication take-back programs, controlled substance lock-in programs, and community-based naloxone distribution.

“Although individuals of all ages have been affected by prescription drug misuse, the health consequences of opioid misuse in the adolescent and young adult population are particularly striking.”

Prescription drug abuse and addiction has reached epidemic proportions in the United States. It is estimated that 1.9 million Americans abuse or are dependent on opioid analgesics and that the rate of opioid-related overdose mortalities has nearly quadrupled since 1999.^1,2 In fact, in 2010, more people in the United States died from drug overdoses than motor vehicle accidents. ³ Although individuals of all ages have been affected by prescription drug misuse, the health consequences of opioid misuse in the adolescent and young adult population are particularly striking. The National Institute on Drug Abuse’s (NIDA) Monitoring the Future survey found that 6 of the top 10 substances used by high school seniors were pharmaceuticals, with 1 in 12 reporting past-year nonmedical use of hydrocodone/acetaminophen and 1 in 20 reporting abuse of oxycodone. ⁴

Given the magnitude of the problem, strategies to prevent initiation of prescription opioid misuse, treat existing opioid use disorders, and prevent overdose are of utmost importance. Prescription drug abuse and overdose is such a threat that the Centers for Disease Control and Prevention added the issue to their list of top 5 public health challenges in 2014. ⁵ This article will provide examples of strategies that are effective in the fight against opioid abuse and overdose.

Prescriber Education

Many prescribers are unaware of the limited evidence regarding long-term effectiveness of opioid therapy and underestimate the risks of use, especially that of addiction. A recent systematic review published in the Annals of Internal Medicine concluded that there was insufficient evidence to determine the effectiveness of long-term opioid treatment in chronic pain but sufficient evidence supporting a dose-dependent risk for serious harms, including overdose and death. ⁶ Other, recent studies suggest that long-term opioid therapy may even worsen pain.^7,8 High-quality, long-term clinical trials assessing the safety and efficacy of opioid treatment are necessary to refine best practice in the treatment of chronic pain. Until available, improved education of the current evidence should be undertaken.

Several states have mandated prescriber education legislation to improve safe prescribing for pain and assist providers in identifying, preventing, and treating substance use disorders. The NIDA and the National Institutes of Health Pain Consortium have established 12 Centers of Excellence in Pain Education, which train physicians in the treatment of pain. The NIDA, in collaboration with the Office of National Drug Control Policy, has also developed continuing medical education modules that prescribers can complete to enhance their knowledge in this area. ⁹

Prescription Drug Monitoring Programs (PDMPs)

PDMPs are statewide databases designed to address prescription drug diversion and abuse. They help prescribers identify drug-seeking behavior and doctor shopping. Access varies by state, but it can include prescribers, pharmacists, and law enforcement. In 2002, the federal government began issuing grants to help support states planning, establishing, or enhancing PDMPs. As of June 2012, 50 states have passed legislation authorizing development of PDMPs, and 40 states had operational PDMPs. ¹⁰

Evidence supporting the use of PDMPs comes largely from observational studies and prescriber surveys. A study from 2010 found that opioid prescribing patterns were influenced when PDMP data were used in an emergency room (ER) setting. ¹¹ The study found that just less than half (41%) of ER visits in which opioids were considered for nontraumatic pain were influenced by PDMP data. Of those cases, 61% of patients received less opioid pain medications than originally planned or no opioid pain medication, based on information found in the PDMP. A second study assessed the number of extended-release oxycodone prescriptions in various states to determine whether an association exists between rate of prescribing and the presence of a PDMP. ¹² The study found that of the 10 states with the highest rate of oxycodone prescription, only 2 had operational PDMPs. Conversely, 6 of the 10 states with the lowest number of oxycodone prescriptions had operational PDMPs.

There are certainly limitations to the use of PDMPs. First, there is very little interstate data sharing. This limits the detection of diversion when individuals obtain opioids from various states and is particularly problematic in areas near state borders. Second, the rate at which data are updated within the PDMPs differs from state to state, with very few states providing real-time access to prescription information. Third, there is limited awareness of PDMPs, and not all prescribers utilize the technology. As of October 2014, only 22 states have regulations that require prescribers to reference the PDMP in certain circumstances. ¹³ Finally, PDMPs can be time burdensome on the clinicians who use them. Better data sharing and data consistency, timely exchange of information, and easy accessibility are all necessary to optimize the effectiveness of PDMPs.

Drug Take-Back Programs and Safe Drug Disposal

Of the people taking prescription drugs nonmedically, 54% reported obtaining the medication from a friend or relative at no cost, 10.9% bought the medication from a friend or relative, and 4% stole the medication from a friend or relative. ¹ This makes community medicine cabinets a primary source of drug abuse and overdose. On September 9, 2014, the Drug Enforcement Agency published a final rule, allowing ultimate users to deliver unused pharmaceutical controlled substances to appropriate entities for safe and effective disposal. An ultimate user is a person who lawfully obtains and possesses a controlled substance for personal use or use by a member of his/her household, including animals. This law expands the options for disposal of pharmaceutical controlled substances (options vary by state) and is yet another strategy for preventing opioid abuse and overdose.

Inventory data from several medication take-back initiatives indicate that just <10% of all medications returned through take-back programs are controlled substances; 21% to 32% of these were hydrocodone combination medications, and 11% to 21.2% were oxycodone or oxycodone combinations. ¹⁴ The significant quantity of controlled substances returned through take-back events emphasize the need for expanded take-back opportunities within our communities.

Controlled Substance Lock-in Programs

The Centers for Disease Control and Prevention estimate that 80% of all abused or misused controlled substance begin as lawful prescriptions. ¹ This finding suggests the need to regulate legal processes by which controlled substances are prescribed and dispensed. Controlled substance lock-in programs are one such strategy. The programs are currently used in state-run Medicaid programs and work through identification of high-risk beneficiaries and “locking” them to a single physician and pharmacy to obtain controlled substances. The definition of high-risk behaviors and the criteria that enroll beneficiaries into lock-in programs vary by state but include use of multiple prescribers for controlled substances, receipt of prescriptions that exceed recommended daily doses, and receipt of multiple controlled substances that fall within the same therapeutic class.

Evaluation of lock-in programs is limited. However, a study in Louisiana found that use of a lock-in program was associated with a significant reduction in polypharmacy, prescription of schedule II controlled substances, and overall prescription costs. ¹⁵ A second study found that Oklahoma’s lock-in program was associated with reduced narcotic analgesic prescriptions, polypharmacy, doctor shopping, and ER visits. This particular program resulted in a $600 mean savings per lock-in enrollee. ¹⁶

Lock-in programs are not without limitations. For example, lock-in programs do not identify or regulate controlled substance prescription or dispensing for which the patient pays cash. The programs are only effective in regulating physician and pharmacy services for which the beneficiary seeks reimbursement from Medicaid. Additionally, Medicaid cannot restrict reimbursement for emergency medical services.

Although the evaluation data regarding lock-in programs is promising, additional assessment is necessary to determine the most effective program structure, specifically, identifying which high-risk behaviors to designate as enrollment criteria. Additionally, the feasibility of lock-in strategies among non-Medicaid payers should be explored.

Naloxone Distribution

Each day, 100 people in the United States die of drug overdose, with approximately 45 of these deaths attributed to prescription painkillers.^17,18 Naloxone is a safe, effective, pharmacotherapeutic option for reversing respiratory depression, if given in a timely manner following opioid overdose. One strategy for preventing opioid overdose is by making naloxone more readily accessible to individuals who would most likely encounter a person experiencing an opioid overdose. Examples of such persons include patients at high risk for overdose and their family members and first-responder law enforcement agents. Because bystander administration is considered an off-label use of naloxone, special laws are required to allow such application. As of October 2013, 10 states have legislation implementing Opioid Overdose Prevention Programs (OOPPs), including naloxone administered by lay persons. ¹⁹ These laws parallel regulations protecting lay-person administration of epinephrine for anaphylaxis or use of defibrillators in cardiac arrest.

A recent review of community OOPPs found that participation in OOPPs by nonmedical bystanders is associated with overdose reversals, increased knowledge and skills in responding to overdose situations, and the ability to safely administer naloxone. ²⁰ Another study by Walley et al ²¹ found observational evidence that comprehensive OOPPs may reduce mortality rates from overdose. The study by Walley et al took place in Massachusetts and trained 2912 potential bystanders who reported 327 rescues. Opioid overdose death rates were reduced in communities in which the OOPPs were implemented.

Law enforcement agents are also positioned to reverse opioid overdose through the administration of naloxone. A study by Rando et al, found that naloxone administration by police first responders was associated with decreased mortality in opioid overdose victims. ²² Opioid overdose deaths increased in Lorain County, Ohio, prior to the initiation of the police officer naloxone administration program, averaging 15.3 deaths per quarter in 2012 and 16.3 deaths per quarter in 2013. After initiation of the program, opioid overdose deaths decreased each quarter, with an overall average of 13.4. In total, 67 victims received naloxone from police officers. Of those individuals, 52 (77%) survived, and 8 (11.9%) were lost to follow-up.

Although initial evidence seems to support naloxone distribution to law enforcement agents and through OOPPs, many policy makers fear liability, an endorsement of drug abuse, and increased drug use. Further well-designed studies are necessary to determine the extent to which law enforcement naloxone distribution and OOPPs reduce overdose morbidity and mortality and find best practices for implementing these strategies in the community.

Conclusion

Although there is a legitimate and necessary place for opioid therapy in the treatment of pain, high-quality research assessing the safety and effectiveness is necessary to refine best practices in opioid prescribing. There are a number of strategies that can be used by various stakeholders to reduce new opioid misuse cases, control and treat existing opioid use disorders, and prevent opioid overdose and death. Support, improvement, and expansion through further assessment of these strategies is needed.