An Exploration of Opioid Use in the United States

By Jason Fischel, MD FACEP

UMASS AmherstPracticum for Public PracticeKathryn Tracy, DrPH MPASummer 2016

Site SupervisorDavid Jaslow, MD MPH

Abstract

The purpose of this manuscript was to explore the opioid epidemic in the

United States with evidence from scientific literature to help elucidate important

research questions. Several questions were addressed in this manuscript.

Questions pertained to the scope of the actual public health problem in addition to

its etiology. Other important aspects of the manuscript assess the role of the media

in the daily discussion of opioid abuse, in addition to important resources that are

available to those who suffer from opioid addiction. This manuscript is the

culmination a of self guided evidence-based research review from the scientific

literature.

There has been a tremendous amount of media attention in the past several

years about the perceived rates of opioid abuse. Daily, the media covers stories that

pertain to opioid abuse, deaths related to overdoses of heroin or other opioids, or

the importance of first responders carrying the opioid antidote naloxone. Just

recently, even The Wall Street Journal(Kamp, 2016) reported on opioid related

deaths in Maine from the year prior. The number of deaths was “record setting.” It

reported on the debate in Maine regarding the state’s discussion surrounding the

increased availability and broad use of naloxone by laypersons. The topics of opioid

and heroin addiction have become extremely political and mainstream. The goal of

this manuscript is help refocus the discussion on opioid addiction and the scope of

the public health problem based on scientific evidence.

In part, this topic would seem controversial because different sources quote

many different statistics when discussing the depth of the public health problem

surrounding opioid abuse and overdose. The Centers for Disease Control and

Prevention report quite clearly that the trend in opioid abuse is alarming (CDC,

2016). In 2014, more people died from overdoses than in any other year. Over half

of these overdoses involved an opioid. The CDC reports that opioid pain relievers

are a driving force in the number of opioid related deaths. They further cite the age

adjusted death rate from overdoses including any opioid has quadrupled since 1999

(CDC, 2016). In fact, in 2007, overdoses surpassed motor vehicle collisions as the

leading cause of injury death (Beauchamp, 2014).

In 2010, 12.2 million people reported using pain relievers for nonmedical

purposes in the past month for the first time (Meyer, 2014). According to the

Substance Abuse and Mental Health Services Administration, after marijuana,

nonmedical use of prescription pain relievers is the second most common type of

drug use. It also reported the most commonly abused drugs included oxycodone,

hydrocodone, methadone, morphine, and, codeine (Meyer, 2014). It is not

surprising that the unintentional overdose death rate increased 124% between

1999 and 2007. It is thought that the majority of these deaths are related to opioid

use.

While the statistics clearly point to a significant threat to the health of the

population, part of the issue with this public health problem is clearly defining the

problem. Rates of opioid abuse are commonly quoted. However, depending on the

source, the quoted numbers seem variable. In addition, defining the terms abuse,

misuse, dependency, and addiction is also important (Vowles, 2015). Without

knowing the exact definition of a term a study is trying to quantify, significant

confusion or misinterpretation of data can occur. One study attempted to define

these terms and quantify the rate of opioid misuse in patients who receive the

medication for chronic pain. This is important because patients who receive opioids

for chronic pain seem to be at particularly high-risk group for opioid abuse.

The study was a systematic review by Vowles and colleagues in 2015 that

was published in a mainstream peer reviewed journal. Other papers were used in

order to calculate rates of concerning opioid use, however, the studies that were

analyzed were rated for quality prior to inclusion in the analysis. As mentioned,

previous studies had quoted problematic opioid use amongst patients with chronic

pain between 0 to 50% of the time (Vowles, 2015). A similar number has been found

in anther study. This huge variability has little utility in defining the scope of a

public health problem. In this study, overall rates of abuse ranged from .08 to 81%

and addiction from .7 to 34%. However, when only high quality studies were

evaluated the rates for misuse were .2 to 56% and addiction from .7 to 23%. Misuse

has a broad definition and includes disorganized use, underuse, overuse, and use in

conjunction with other substances such as alcohol.

However, this study was criticized by another author for inclusion of studies

that were, in fact, of low quality. Scholten and Henningfiled point out that the

definition of opioid misuse in the above study is identical to “patient

noncompliance.” Their work suggests opioid noncompliance is similar to the

general patient population noncompliance rate with other medications after

comparison with another meta analysis (Scholten, 2016). In addition, though

Vowles reports rating the studies for quality, many of the studies were rejected by a

Cochrane review because they were found to be low in quality. As such, the

Cochrane review was unable to publish a meta analysis, but rather published a

literature review. The Cochrane findings were in stark contrast to Vowles’s

conclusion and found that opioid use for chronic pain does not seem to be a major

risk for opioid dependence. Moreover, likely the most important finding is that

there is a dearth of high quality research on this topic.

Few would contest that the rates of opioid use are increasing. Given this, it is

not surprising that the rates of opioid sales are increasing. The number of

outpatient retail prescriptions tripled over the last two decades with its peak in

2011 at 219 million (Compton, 2015). This begs examination of physician

prescribing patterns. Certainly, the aforementioned rise in opioid use would

ultimately not be possible without an increase in physician prescribing.

Physicians are, in fact, writing a far greater number of prescriptions for

opioids. This is well documented in the literature. After all, pain is the number one

complaint why patients present to the emergency department (Poon, 2014). One

recent study attempted to analyze the trends in opioid prescribing from physicians

practicing in emergency departments. The study, done by Mazer-Amirshahi and

colleagues was published in 2014. It is a retrospective analysis of publicly available

data from the National Hospital Ambulatory Care Survey from 2001 to 2010. The

database is maintained by the Centers for Disease Control and Prevention. The

study found opioid prescribing increased from 20.8% to 30% over the study period.

This represents a relative increase of 49%. DEA schedule 2 narcotic use also

increased from 7.6 to 14.5%, a relative increase of 90.8%. Upon discharge from the

emergency department, oxycodone and hydrocodone had the greatest relative

increases over the study period (Mazer-Amirshahi, 2014).

There is no doubt that emergency physicians prescribe a lot of opioids.

Several studies have tried to quantify how often patients leaving the emergency

department are given opioid prescriptions. One study performed a retrospective

analysis of 19 emergency departments for a one-week period in October 2012

(Hoppe, 2015). There were 27,516 patients seen.  19,321 were discharged.  3,284

patients received an opioid on discharge.  The average age of the patients who

received an opioid prescription was 41.  Oxycodone and hydrocodone were by far

the most common opioids prescribed on discharge.  The median number of pills

prescribed was 15 (Hoppe, 2015).

Interestingly, a study in 2016 was performed to assess characteristics of

emergency physicians and their prescribing habits (Varney, 2016). The concept of

the study is interesting and begs further investigation.  However, this particular

paper is not further described as the study participants were all based out of a

single military hospital and very homogeneous in make up.  A larger study including

multiple centers with a much larger number of physicians would be an beneficial

area for further study.

It is not just emergency physicians who are prescribing lots of opioids. One

study looked at prescriptions for opioids from a prescription database (Vector one

National database from SDI Health) for 2009 by specialty. This database receives

prescription information from more than 30,000 of the 62,132 pharmacies in the

country. This represents approximately half of the prescriptions filled in the US

annually. Most prescriptions were for hydrocodone and oxycodone containing

products. 28.8% of the prescriptions were from primary care providers (general

practitioner, family medicine, osteopathic physicians). Internists wrote 14.6%

followed by dentists at 6.1%. Orthopedists wrote 7.7%. For the 10-19 year age

group, emergency physicians wrote the third most prescriptions at 12.3% (Volkow,

2011). Of note, it was interesting that osteopathic physicians as a group were

lumped in primary care providers. This is obviously an error in methodology as

osteopathic physicians specialize in many different areas of medicine.

While it is clear that emergency physicians are amongst a group of physicians

who prescribe a significant amount of opioids, it is important to decipher if the

increased prescribing has any relation to addiction. One study from 2015 published

in the Annals of Emergency Medicine attempted to clarify this. The study authors

tracked patients who were considered opioid naïve by the state prescription

monitoring program to see if they received an additional script within 425 days of

the index emergency physician prescription (Hoppe, 2015). The data did show

those who received and filled a prescription were 10% more likely to have filled a

second prescription within that time period. Though an interesting finding, the

study had many limitations. Chiefly, it was only performed at one center. This

limits external validity. The baseline characteristics between those who received an

opioid prescription and those who did not, were statistically different. In addition,

the study did not take into account who gave and why the second script was given.

There is a fundamental disregard for confounding (Hoppe, 2015).

Butler et al attempted a similar study later that year. She and her team

approached patients in their emergency department who were identified as using

heroin or non-medicinal use of opioids and surveyed them about their first

experience with opioids (Butler, 2015). Of the 122 patients approached, 59

completed the full survey. 59% of these patient reported their initial exposure to

opioids occurred from a legitimate medical prescription. Of those patients, only

29% of them received that prescription from an emergency department (Butler,

2015). Importantly, 80% of these patients reported non-opioid substance abuse or

treatment prior to the opioid exposure. This study had numerous limitations. The

most notable limitations were the small sample size and convenience sample that

was used. In addition, it was subject to considerable recall bias. However, similar to

the Hoppe 2015 study, it focuses on an area that raises important questions about

potential origins of opioid addiction and the role of iatrogenic opioid addiction after

a short course of opioid use.

It would seem the origins of the increased prescribing of opioids is not hard

to trace. In the early 80’s, reports emerged in the scientific literature that suggested

opioids had a low potential of iatrogenic addiction (Beauchamp, 2014). This was

supported in a consensus paper published in 1997 by the American Academy of

Pain Medicine and The American Pain Society. The consensus paper urged

clinicians to more strongly assess and treat patients’ pain. It identified chronic pain,

and makes mention that the chronic pain may even derive from conditions other

than cancer. It further points to the huge social cost associated with pain and urges

“dialogue” between clinicians and regulators so as to not interfere with appropriate

management of pain.

At the same time, the drug industry began a strong marketing push. Between

1995 and 2006, Purdue Pharma funded 20,000 pain related educational programs

that supported using opioids for noncancer pain (Kolodny, 2015). According to a

government report, in 2001, oxycontin was the most prescribed brand named

narcotic for moderate to severe pain (US GAO, 2013). Purdue Pharma was even

giving financial support to the Joint Commission. Purdue and the Joint Commission

made an agreement that Purdue was the only drug company allowed to distribute

certain educational materials and an educational book about pain management.

This book was even available for purchase on the Joint Commission’s website (US

GAO, 2013).

Then, in 1995, the president of the American Pain Society presented a new

campaign for the aggressive pain management. It was called “Pain is the fifth vital

sign” (Kolodny, 2015). Though this sounds fairly innocuous, it has a very deep

meaning. To practicing physicians, the classic four vital signs (heart rate, blood

pressure, respiratory rate, and temperature) are exactly as the name describes, vital.

To suggest that an assessment of pain be a new, fifth vital sign is actually

tremendously significant. The Joint Commission soon adopted this as well. In fact,

the Joint Commission had proposed patient’s rights standards in 2000 that

mandated patients being involved in their care, including the realm of pain

management, amongst other topics. They further mandated that pain be

recognized and addressed appropriately (US Veterans Administration, 2000). These

proposed standards were adopted in 2001.

While researching the Joint Commission and their pain standards one can see

a statement from the Joint commission website that takes a rather defensive

posture. It begins with comments that “everyone is looking for someone to blame”

with respect to the cause of the current opioid epidemic. In it, it addresses five

misconceptions about the Joint Commission. They include; “The Joint Commission

endorses pain as a vital sign,” “the Joint Commission requires a pain assessment for

all patients,” “the Joint Commission standards push doctors to prescribe opioids,”

“the Joint Commission requires that pain be treated until the pain score is zero”, and

“the Joint Commission pain standards caused a sharp rise in opioid prescriptions”

(The Joint Commission, 2016). Though the Joint Commission’s position is rather

clear from their website statements, to even suggest they did not have a role in the

increased prescribing in opioids is disingenuous.

Another factor has likely also led to the increase in opioid use for pain

management. Patient satisfaction scores are becoming an integral part of

healthcare. Hospitals frequently use a patient satisfaction device to rate patient

experience, both for inpatients and outpatients. Many vendors exist and are

approved to survey patients (HCAHPS, n.d.). Recently, the centers for Medicare and

Medicaid Services and the Agency for Healthcare Research and Quality developed

HCAPS. Voluntary reporting was first started in 2007. One topic addressed in the

survey is pain management by the clinical team. This is very important as the

survey results are publicly reported and are tied to hospital reimbursement.

Further, emergency physician compensation is often times tied to provider

satisfaction surveys. Interestingly, in July 2016, the Centers for Medicare and

Medicaid Services proposed dropping questions regarding pain management from

patient satisfactions surveys (HCAHPS, n.d.).

One more cause of the opioid use epidemic may be related to media

attention. Though the media would say they are only reporting on fact, there is

evidence that suggests otherwise. Dasgupta and colleagues assessed the temporal

association between the news media and opioid related mortality. This was an

intriguing study that cites similar relationships with prior substances that have

generated media speculation prior to the current opioid epidemic for the past

several decades (Dasgupta, 2009). The study correctly points out that the individual

predisposition and a complex relationship between biology and ones environment

are crucial to determining potential addiction. The news media may make an

important contribution to the one’s environment (Dasgupta, 2009).

A time series of unintentional deaths involving opioids from 1999 to 2005 in

the US was obtained by reviewing the National Center for Health Statistics by ICD 10

codes. Monthly counts of news articles were gathered from the Google Search

Archives from the same period in 2008 (Dasgupta, 2009). This provides news

articles in English from approximately 25,000 news media sources. The month,

year, and publication title were evaluated for certain key terms. The articles were

then reviewed. There were approximately 24,000 news articles discussing opioid

abuse from a total of about 31million articles in the Google Search Archives. A time

lagged correlation was then created between the mortality rates and the news

media reports (Dasgupta, 2009). News media was found to be a significant

predictor of mortality. Heavy news media coverage preceded poisoning deaths by

two to six months.

The article does cite several news media stories that may inadvertently

endorse opioid use. One such article was entitled “Euphoria Envelopes your body in

a warm, cozy hug. Problems dissolve. Limbs tingle. Life is perfect. These are the

sensations that drug addict Christopher Coughlin says he felt using Oxycontin, a

highly addictive opiate that is sweeping Maine, from the streets of South Portland to

the rural communities of Washington County.” Such articles have a flashy title likely

to entice the reader, but do not disclose the dangers of non-medicinal opioid use

until late in the headline. A similar trend was found in many other news media

stories (Dasgupta, 2009).

Interestingly, according to the Scholten article, the media reported on the

Vowles 2015 study that was previously discussed. The Vowles article was used to

quote high rates of opioid dependence following opioid use for chronic pain.

Scholten does not cite this. However, it is not surprising. A simple Google search by

this author for “Vowles, news media, and opioid” revealed the first search return

was a summary story by Wolterskluwer.com. The second match was a link to the

original article by Vowles. The third return was a summary article published by

physician weekly.com.

A 2016 McGinty study assessed media framing of opioid abuse. A search was

performed of Lexis Nexis, Proquest, and NewsBank online archives. Search terms

included 11 names of opioids in addition to words such as “addict,” “abuse,” and

“overdose”. The review found a total of 4,625 news print stories and 654 television

stories from 1998 to 2012 (McGinty, 2016). This article is only mentioned here to

show the pervasive nature of opioid coverage in the media.

Given all the media attention, it is not surprising that opioids have caught the

attention of politicians. The State of Connecticut seems to have a robust program

available for those who are seeking assistance with opioid addiction. The state

Department of Health and Addiction Services (DMHAS) has a website which

provides an overview of their programs. They also work closely with the Substance

Abuse and Mental Health Services Administration, which is a federal program.

According to the DMHAS website, it is their belief that “most people with mental

illness and/or substance use disorders can and should be treated in the community

setting, and that inpatient treatment should be used only when absolutely necessary

to meet the best interests of the patient.” As such, they have a wide array of

contractors who provide addiction services.

In Connecticut region 1, there are 18 facilities, which receive funding to

provide such services in various different cities. There are also two crisis-

intervention centers affiliated with region 1 (DHMAS, 2016). There are also

referrals available for self-help groups such as narcotics anonymous and a statewide

narcotics task force. The state website also has lists of clinics that are able to offer

methadone, buprenophine, and naltrexone; adjunct medication treatment for

patients with addiction to opioids. Patients in need of services can enter treatment

in any of these programs through a variety of ways, and are frequently referred

from local hospitals or practitioners. A detailed list of resources offered by every

local hospital is far beyond the scope of this manuscript.

Connecticut has also passed legislation with intent to ensure practitioners

are performing due diligence when prescribing opioids. The Connecticut

prescription-monitoring program is run by the Connecticut Department of

Consumer Protection. It collects prescription data on Schedule II through Schedule

V drugs in a database. According to the state website, its intended use is for

practitioners to have real time information “on the complete picture of a patients

controlled substance use” (Connecticut Department of Consumer Protection, 2016).

New laws enacted in 2015 require that practitioners review a patients’ Connecticut

Prescription Monitoring and Reporting System report prior to prescribing a 72-hour

supply of a controlled substance. When providing a long-term supply of narcotics, it

also requires occasional review of the report for the patient (Connecticut

Department of Consumer Protection, 2016). In addition, this law also requires

physicians to perform continuing education on substance abuse and pain

management.

Naloxone is a medication that has been written about significantly in the press

recently. It is an opioid antagonist. In other words, it is the antidote to opioid

overdose. It is a medication that has been used by trained professionals for many

decades in the setting of acute opioid overdose. However, in wake of the national

media attention, the medication was thrust into the spotlight. Many articles such as

the US today article “Police carry special drug to reverse heroin overdoses” from

2014 by Donna Leinwand discusses the use of naloxone by first responders.

While there is no doubt the medication naloxone works, its broad prehospital

use has been controversial. Those opposed to the broad use, point to the fear of

potential increased rates of overdose. There is concern that patients may not seek

adequate care and lack the correct knowledge that naloxone does not treat

underlying addiction. Some studies have been performed to assess the utility and

potential benefit of these naloxone programs.

Currently, important organizations have endorsed the broad use of naloxone by

lay persons. The CDC reports “providing naloxone kits to laypersons reduces

overdose deaths, is safe, and cost effective.” These recommendations seem to come

after review of a survey from the Harm Reduction Coalition (HRC). The HRC had a

database of organizations that provided naloxone to laypersons (CDC, 2014). The

HRC performed an online survey of 140 organization managers from health

departments, healthcare facilities, pharmacies, and substance abuse programs. 109

different organizations collected information about reversals. There were

approximately 25,000 reports of reversals (CDC, 2014). The data provided by the

CDC in this descriptive study is descriptive. While the numbers seemed very

convincing, the nature of its collection seems subject to significant bias.

The American Academy of Clinical Toxicology, the American College of

Medical Toxicology, and the American Association of Poison Control Centers also

published a position paper in 2014 which calls for increased access to naloxone by

laypeople (Doyon, 2014). They report there is little data on outcomes of such

programs. They report naloxone administration is an important harm reduction

tool. They recognize that is just one important element in a multifaceted approach

to reduce the public health cost of narcotic addiction. They also cite the need to

gather more data regarding the effectiveness of bystander-administered naloxone

(Doyon, 2014). They also see legislation as important obstacle to the development

of such programs. However, the position paper also recognizes these patients need

significant aftercare, and the medication administration is certainly not the ultimate

intervention these patients need (Doyon, 2014).

As the programs have demonstrated increased success, Connecticut law

became far more favorable to prescribing naloxone over the past several years.

According the DMHAS website, in 2011 a good Samaritan law was first passed that

made those who called 911 to report an overdose protected from prosecution from

possession of drugs or drug paraphernalia. This law does not protect the person

from other charges. In addition, if the police were in the process of executing a

search warrant, it does not provide protection in that circumstance (DHMAS, 2016).

The following year a law was passed that allowed health care prescribers to

prescribe, dispense, or administer naloxone to any person to prevent an overdose

with protection from civil or criminal prosecution (DHMAS, 2016). In 2014 that law

was extended to anyone administering naloxone. Interestingly, in 2015 legislation

allowed pharmacists to dispense naloxone to anyone who requested it. The

pharmacist must receive training on how to administer the medication and must

also teach the person on its use. Finally, in 2016, state law required all first

responders to be trained and equipped with naloxone.

The practicum experience that I chose was one that was focused on self study

of a topic that I felt was fascinating, of great public health concern, as well as

relevant to my every-day life as a practicing emergency physician. It was a topic

that I had many questions about, as I felt the media was driving much of the

discussion with respect to narcotic abuse. As such, I felt I was getting a very biased

presentation of “fact.” The chance to work on a scholarly project preparing a

manuscript was ideal for me as I consider further pursuing a career in academia. I

feel my manuscript is evidence-based and discussed many difficult topics that

people feel passionately about, but may be biased based on their emotions or

previous personal experience.

One highlight of the experience was the process of self-directed research.

Often times, I found when I was focusing on one area of research, other areas of

interest would arise that were relevant for study. For example, when researching

statistics on opioid abuse, it became very obvious that different authors would focus

on different types of patients abusing opioids. This led to further questions and the

need to delve into other areas of discussion that I had not previously thought about

when considering this practicum topic. Much of my time was spent in front of a

computer researching the topic. I would spend many hours performing literature

searches and finding articles. I would frequently cross-reference other articles that

seemed relevant. Though emergency medicine seems core to the opioid abuse

discussion, at least in terms of acute management, at times it was difficult to find

articles that were published in emergency medicine literature. I was frequently

finding important literature in the addiction literature, which leads me to believe

that the emergency medicine community has more work to do with respect to

research on this important public health topic.

However, research at times was also frustrating. There were many times I

thought a topic would have been researched and publications would be available on

a given subject given its popularity. In fact I could not find articles about some

topics that were instrumental in broaching. This led me to be to believe that though

narcotic abuse is widely discussed, there is still much more research that needs to

be completed. While it is clear that opioid abuse is very prevalent, many more facets

of the problem need further elucidation.

This type of practicum experience is ideal for a motivated student with

specific research questions. One must stay disciplined when participating in self-

guided work. It is easy to fall behind. In addition, the student must have at least one

or two research questions. I think they must have some idea as to what they want to

study; otherwise the opportunity may seem very daunting. Even if they have one

question and start their research they may expand the topic with several other areas

of inquiry, which is desirable. However, without some guidance it is easy to get lost

in the project.

Conclusion

This manuscript was written as a self-study practicum project with respect to

learning more about opioid abuse. The research was rewarding and very

challenging at times. Though the media likely influences the perception of the

opioid use, it is clear opioid abuse is certainly at an all time high. The community

and other stakeholders such as the government have an important roll in creating a

multicoated approach to decreasing opioid use. While many quality projects have

been initiated towards this end, there is still work that needs to be done.

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