Commentary: Four solutions to mitigate the opioid crisis

Pain is a more terrible lord of mankind than even death itself.- Dr. Albert Schweitzer, 1931.

By Wade Berrettini

Two wonderfully talented artists, Prince and Philip Seymour Hoffman, died in the recent past of opioid overdoses. Opioids are medications (Oxycontin, Vicodin, Dilaudid, Fentanyl, morphine) that relieve severe pain and produce a highly addictive powerful feeling of well-being (euphoria).

About 20 years ago, physician prescribing habits for opioids started to become more liberal, from studies indicating that more aggressive treatment of persistent pain was needed. This increased prescribing of opioids has predictably led to increased prescription opioid abuse with terrible consequences.

Emergency room contacts involving prescription opioids increased from 82.5 per 100,000 in 2004 to 184.1 per 100,000 in 2011. Deaths from prescription opioid overdoses soared from 1.4 per 100,000 in 1999 to 5.1 over 15 years. There were more deaths from prescription opioids in 2013 than all illegal (illicit) drugs combined.

The transition from occasional misuse of illicit prescription opioids to addiction can be a rapid progression, occurring over weeks to months. Once addiction to prescription opioids is established in a patient, the transition to regular heroin (another opioid) use is often a consequence, because heroin is less expensive and produces a very similar sought-after euphoria, especially when smoked, snorted, or injected.

What can be done to mitigate this tragedy?

While opioids are excellent in relieving acute pain, they are less well-suited to treat chronic pain due to side effects and because tolerance develops, so higher doses are needed, leading to more side effects. The medical profession must provide chronic nonprogressive pain patients with greater access to alternative treatments, such as nerve blocks, stimulators, and acupuncture. Greater numbers of pain-medicine specialists are needed. The World Health Organization estimates that 22 percent of primary-care patients have chronic pain.

Second, greater investment in pain research is needed to identify compounds and devices that can relieve severe chronic nonprogressive pain without such risk for addiction. Research is needed to identify patients at high risk for opioid addiction, so that preventative measures (counseling and close monitoring) can be instituted should opioids be required for severe pain.

Third, a nationwide prescription-drug monitoring program is needed for prescription opioids (and other addictive medications), so that addicted patients are less able to obtain such medications from multiple physicians. In such a program, the details of the prescription for a covered medication are reported by the dispensing pharmacy to the nationwide database, and any physician prescribing for that patient has access to his/her prescription history. Hopefully, this would lead to earlier identification of those needing opioid addiction treatment.

Fourth, we must improve our ability to provide effective treatments for opioid-addicted individuals. This includes regular counseling, self-help groups, and medications to assist the patient in maintaining abstinence from illicit opioids. There are three Food and Drug Administration-approved medications for the treatment of opioid addiction. This is nowhere more true than in our prisons, where so many returning citizens need treatment for opioid addiction upon parole.

Currently, prescription opioids are a pillar of hope when faced with that "terrible lord of mankind." Collectively, we must deal more effectively with their risks.

For all these reasons and more, it is incumbent upon our elected officials to take bold, decisive action to significantly reduce opioid addiction. Increased funding for research, prevention, and treatment programs is critical to making significant headway in saving lives and ending a cycle of addiction in communities across the nation.

Legislation that expands opioid-addiction treatment, recently signed into law, is a step in the right direction, but falls short of the funding needed to adequately address this epidemic.

The next Congress and new administration must do more to give communities sufficient resources to combat this public health threat.

Wade Berrettini is the Karl E. Rickels professor of psychiatry at the University of Pennsylvania's Perelman School of Medicine. wadeb@mail.med.upenn.edu

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