The Medical Irony of the Deadly Opioid Epidemic

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BRIEF COMMUNICATION

Dr Sederer is Adjunct Professor, Department of Epidemiology, Columbia University Mailman School of Public Health, Distinguished Psychiatrist Advisor to the New York State Office of Mental Health (OMH), and Director, Columbia Psychiatry Media.

My goal in this article is to persuade you, doctors and nurses who have prescribing authority, to save lives by prescribing an opioid drug for the opioid epidemic-namely buprenorphine. Including those practicing psychiatry, primary care, neurology, pain medicine, and so on. While you are at it, don’t miss the chance to help your patients (and their families) obtain the opioid reversal drug, naloxone.

The irony here is that prescribing (or assisting in dispensing) these (often highly stigmatized) drugs will forestall more drug deaths in the next few years than anything else doctors can do. Not a week passes where I do not meet grieving family members who have lost a loved one to a drug overdose, some still recently in its wake, the others who can never forget. Their loved one, or friend, had been smoking, vaping, or injecting heroin (they are beyond pills) or its synthetic close relative OxyContin. Dealers now increasingly lace whatever they are selling with fentanyl. Laboratory synthesized (often in China), this opioid is 50 times more powerful than heroin, 100 times more powerful than morphine. The potency of the opioid was beyond the drug dependent person’s tolerance: first they experienced respiratory distress and then followed an abrupt cessation of breathing.

These are preventable deaths. Despite reductions in medical prescribing of opioids (eg, OxyContin, Vicodin, Percodan), overdose deaths in the US continue to rise. Opioid overdoses annually eclipse motor vehicle deaths and now dwarf the loss of lives from the entire HIV/AIDS epidemic as well as the Vietnam War.

Today’s opioid epidemic traces its roots in good part to doctors’ efforts to change what had been regarded as their under-prescribing of pain medications. Pain became the fifth vital sign. Regulatory agencies expected doctors to administer patient self-reports of pain, which of course demanded a response when scores were high, as they often were. With too little time to spend with patients and a wish to help, the most immediate solution for a physician lay there on the desk-the prescription pad. Patients, too, were seeking a simple and fast solution to their pain. The icing on this not-at-all sweet clinical cake was the prominent Pharma marketing that opioids were not addictive. Doctors, in effect, with no ill intent, believed these drugs were a safe solution to the problem of pain. But their common prescription soon fostered addiction and fueled the growth of the opioid epidemic.

Pain is ubiquitous. Everyone’s body feels it. For some it becomes chronic, potentially disabling. But there is more to this epidemic than arthritic joints, broken bones, tumors, and other dolorous conditions. We now recognize what we call the social determinants of physical, mental, and addictive illnesses. These include unemployment, poverty, housing instability, trauma, and domestic and neighborhood violence. You probably have heard the term, “deaths by despair”? These are deaths from suicide, drug overdoses, and the long-term complications of alcoholism and other addictions. We doctors are in a position to keep people alive until there are prospects for their future (and that of their children), safety, or opportunity to find purpose-until they can enter recovery and rebuild what addiction eroded.

Buprenorphine was FDA approved in the US in 2002. In the 1990s, it had reduced drug overdose death by 80% in France (through ready access in primary care). Its use in the US has been terribly impaired by the social stigma of addiction as well as its being the only drug that requires an 8-hour training course and obtaining a DEA number suffix to prescribe it. OxyContin and fentanyl have no such burdensome requirements.

Buprenorphine (Suboxone and others) is an opioid agonist, which means it fills the mu (opioid) brain receptor, impeding another opioid from attaching. Moreover, buprenorphine has a “ceiling effect”-its capacity to produce intoxication and narcosis is limited, unlike other opioids where the more someone takes, the higher they get, until they stop breathing. In effect, this medication provides a safe substitute for a deadly street opioid, while quelling drug cravings. There is no need, as well, to steal, deal, or prostitute oneself to obtain a drug supply, as is the case for all illegally trafficked substances.

Opioid overdoses, too many fatal, are dramatically reduced once someone begins buprenorphine. Doctors and nurses, please take heed. This is a life-saving medication that needs you to prescribe it.

Naloxone, in most states, does not need a prescription. It is an opioid antagonist, the “reversal” drug that immediately blocks the action of any opioid in the body. Breathing resumes, and a life is saved if handy, and administered in time in adequate dosage. Which is why its presence should be everywhere, in any home, office, public building, your briefcase, and in my backpack. Since its nasal spray preparation was introduced, there is no need for an injection, even an auto-pen stabbed into the thigh. Our job as clinicians is to help patients and their families get a supply of naloxone, learn how to use it (which is very simple), and have it nearby should the need arise. Some public health clinics dispense it, like condoms.

I do not mean to suggest that medications alone are the answer to the opioid epidemic raging in this country. Complex problems call for comprehensive solutions, including motivational enhancement (readiness for change), 12-step recovery, cognitive therapy, family education and support, and taking care with what we eat and how we sleep, mindfulness and meditation, and finding people who can help rather than harm you.

Our job as clinicians, our privilege, is to help our patients stay alive until they can engage in and benefit from good treatment, and, in time, recover a life of relationships, contribution, purpose, and meaning. The doctor’s (or nurse’s) prescription pad is the most immediate and effective way to do so. We may have contributed, unintentionally, to the opioid epidemic, but we can, intentionally, help to remedy it.

Dr Sederer’s most recent book, The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs (Scribner, 2018), is now available in paperback.

This article was originally published 5/15/2019 and has since been updated.

Disclosures:

The author reports no conflicts of interest concerning the subject matter of this article.