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The History of the Opioid Epidemic

Daniel McCollum, MD and Jan Shoenberger, MD
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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EMRAP 2018 07 July Vol.18 V2 Written Summary 390 KB - PDF

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Ian L., Dr -

The Viox class action and the collapse of NSAIDS for use in analgesic particularly in the elderly
drove physicians to opt for opiates for severe chronic non cancer pain.
Diversion from the elderly often under duress by family was never anticipated .
Daily pick up dosing under supervision and security protocols ought alleviate .

Mike -

Excellent piece!!! I wish many people in the media would publish similar facts to teach the public the origin of the problem and to lay much of the blame away from prescribers. I suspect fear of EMTALA violation for not stabilizing chronic pain despite no emergent condition may have played a role as well. I was bemused when, about a year ago, I googled “Joint Commission pain is the fifth vital sign” and found they had published a brochure about their reasons and how they never insisted that narcotics be prescribed, so they’re not at fault, blah, blah, blah.

Michael D. -

Thank you for this concise but comprehensive summary of the opioid epidemic.

One of the most frustrating components of the opioid epidemic has been the wholesale failure of hospitals and healthcare systems to accept the role of medication assisted treatment as an evidence based and necessary solution to the epidemic, versus focusing on supply reduction (pushing many of their patients off a cliff) and episodic care for overdose and other related opioid use related illnesses.

If the healthcare system would have taken a more comprehensive approach to addressing the perceived prescribing crisis, we easily could have transitioned patients that had physical dependence to longer term opioid tapers, and patients that had become addicted to their prescribed opioids could have been transitioned onto MAT and combined with psycho-social treatment and other interventions (Buprenorphine has a NNT of 2 for retention in treatment).

The resulting industry (aside from the illegal opioid "industry") that has risen from the alienation of opioid patients is just as perversely profit driven as the large pharmaceutical companies. Episodic, abstinence based treatment programs rarely work, yet saddle our health insurers with immense costs. Outpatient treatment is effective, but even some of the highest quality outpatient opioid treatment programs (many of these high quality programs started by EM physicians) have become focused on profit through the overuse of urine drug screens and confirmatory testing.

I am afraid about how many more people are going to die from overdose, how many more families will be broken, how many more of our healthcare system dollars spent, and how many more providers will burn out from this epidemic before we finally overcome stigma, accept the evidence, and build the policies to address this epidemic as a disease that healthcare systems and the entire healthcare workforce has a role in the solution.

DaveDuBois, MD FACEM -

Your piece echoes what I have been sharing with others as to why this epidemic occurred. I do think there is one more contributor. That would be patient satisfaction surveys that started being used soon after pain as the 5th vital sign was created and pushy detailing by Pharma reps to use Oxycontin. Press Gainey surveys ask about pain relief being asked about and offered. I had several partners that wanted great P-G scores so they always gave the patient what they asked for. I offered a 2-3 Rx for opioids rather than a week plus if I was asked. This generated complaints 3 times in 1 year. The patients were clearly drug seekers on review. However, the CEO of the hospital was worried he would get a lower bonus due to the patient complaints and potentially lower satisfaction scores and asked my boss to fire me. I wasn't fired. But I didn't feel good about that experience and later left that group. I did not change my prescribing either because it was appropriate, but I did spend much longer explaining my decision to my drug-seeking patients. Also, soon after the threat from the CEO, North Carolina created a database that would show if the patient had multiple RXs filled recently and where.

Dallas Holladay, DO -

Great piece! A couple of thoughts. Part of the solution is obviously getting people into treatment and helping society realize that addiction is a medical problem. A big piece of that is destigmatizing addiction so we should probably eliminate words like "junkie" from our vocabulary.

The other sad side of this story is that heroin never left many American neighborhoods, predominantly black neighborhoods. As far as I can tell, this has been a neglected piece of this conversation. Now that opiate addiction has the spotlight, it's important that addiction resources and education are spread to these areas as well.

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