Preventing Opioid Overdose Deaths and Misuse: What Can Psychiatrists Do?

Pain Management

One of the very few aspects of medicine on which there is essentially universal agreement is that it is better to prevent a disease than it is to try to treat it.

It is therefore surprising that with all the attention focused on the treatment of opioid abuse and addiction there has been relatively little thought given to preventing misuse in the first place. Instead, apart from calls for physicians to reduce the number of opioid prescriptions-which has raised concerns about inadequate treatment of pain-most of the focus has been on promoting treatments such as buprenorphine and methadone and the wider availability of naloxone to prevent deaths from overdose.

There is little doubt that opioid misuse is a major public health problem in this country. The CDC recently reported that in 2014 (the most recent year for which data are available) the number of overdose deaths related to both heroin and opioid analgesics reached 28,647.¹

Certainly there are many cases of opioid misuse that are impossible to prevent. Unless someone is in treatment for another physical or mental disorder at the time the opioid use starts, it is unlikely that a psychiatrist will encounter the individual before he or she is already addicted. Moreover, less than 25% of those addicted to prescription opioids receive treatment.²

Although many psychiatrists believe that their non-psychiatrist colleagues have more knowledge about the therapeutic use of opioids than they do, multiple studies have demonstrated the fallacy of this belief.

Whether the abused drug is prescribed by a physician to treat legitimate pain or whether someone is purposely abusing prescription opioids, the involvement of a psychiatrist early in the care of these patients may prevent further abuse or allow for early intervention.

Who are potential prescription opioid abusers? Unfortunately, we don’t have many reliable predictors. The draft of a new CDC guideline on the prescription of opioids for chronic pain states that the only consistent predictive factors for misuse are a history of substance abuse, major depression, use of psychotropic medications, and younger age.³ However, there are patients without these predictive factors who are treated with opioids for legitimate pain complaints who end up abusing them. Essentially everyone for whom an opioid is prescribed for more than a very brief period (eg, for acute pain after an injury or surgery) needs to be considered a potential abuser.

Role for psychiatrists

What role can psychiatrists play in preventing prescription opioid abuse and addiction and the consequent health problems?

Once the decision has been made to prescribe an opioid for a legitimate pain complaint, it may be helpful for a psychiatrist to monitor the patient. However, to provide competent input and to determine when a patient is trying to deceive the physician into providing prescriptions, psychiatrists need to understand the appropriate use of opioids for pain management.

Although many psychiatrists believe that their non-psychiatrist colleagues have more knowledge about the therapeutic use of opioids than they do, multiple studies have demonstrated the fallacy of this belief.

A recent study surveyed members of departments of anesthesiology, surgery, obstetrics, and medicine at all levels of training-including medical students, residents, and attending physicians-at a major American medical center.⁴ The participants were asked what they knew about opioids. Although those in anesthesiology generally did better than those in the other departments, none of the departments had a passing score on level of knowledge. Furthermore, the level of training made no difference: attending physicians didn’t know any more than residents or medical students.

The limited involvement of psychiatrists in prescribing opioids is reflected in another study that utilized Medicare Part D prescription data to examine which specialties prescribe the most opioids.⁵ The top 4 prescribers were (1) family practice, (2) internal medicine, (3) nurse practitioners, and (4) physician assistants. Psychiatry did not even make the top 25 specialties and professions. I doubt that many psychiatrists would disagree that they in general receive much more training and are more knowledgeable about opioid abuse than any of their health care colleagues on the list.

Finally, another recent study coauthored by the 2015 Nobel Prize winner in economics, Angus Deaton, highlights the important role that psychiatry might play.⁶ The findings indicate a marked increase in deaths of white non-Hispanic men and women aged 45 to 54 years in the US between 1999 and 2013. If the death rate for this group had stayed at its 1998 level, there would have been 96,000 fewer deaths; and if the rate had declined as it had from 1978 to 1998, there would have been almost 500,000 fewer deaths. The higher mortality was due to increases in suicide, drug and alcohol poisoning, and chronic liver diseases and cirrhosis. There were also increases in chronic pain and inability to work.

There is an obvious interrelationship between all these problems. Although the authors acknowledged that it was impossible to tell which problem preceded the others, it is clear that chronic pain is associated with increased risks of suicide and drug and alcohol abuse. Even the liver diseases that might, at first, simply be attributed to alcohol use or intravenous drug use might have a relationship to pain. Among the most prescribed opioids are hydrocodone and oxycodone in combination with acetaminophen. Opioid abusers who use these drugs might easily exceed daily acetaminophen dose limits, resulting in hepatic toxicity.

There is no guarantee that greater involvement of psychiatrists in pain management would significantly affect prescription opioid misuse or reduce the rising death rate found in the study by Case and Deaton.⁶ But considering that virtually all current efforts are focused on treating these problems after they have occurred, aren’t attempts to prevent them worth trying-especially given that we still have only limited knowledge about the best way to treat iatrogenic opioid misuse?

References:

1. Rudd RA, Aleshire N, Zibbell JE, et al. Increases in drug and opioid overdose deaths: United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2015;64:1-5.

2. Han B, Compton WM, Jones CM, et al. Nonmedical prescription use and use disorders among adults aged 18 through 64 in the United States, 2003-2013. JAMA. 2015;314:1468-1478.

3. Centers for Disease Control and Prevention. Guideline for prescribing opioids for chronic pain: United States, 2016. www.regulations.gov/#!document Details;D=CDC-2015-0112-002. Accessed February 11, 2016.

4. Goldberg SF, Baratta JL, Wenzel JT, et al. Initiative to improve opioid knowledge and prescription practices in primary providers. Presented at: Annual Meeting of the American Society of Anesthesiologists; October 2015; San Diego, CA.

5. Chen JH, Humphreys K, Shah NH, Lembke A. Distribution of opioids by different types of Medicare prescribers. JAMA Intern Med. 2015;276:259-261.

6. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. PNAS. 2015;112:15078-15083.