A State of Addiction: The Fifth Vital Sign
Since 1999, opioid-related overdoses have quadrupled in the United States, and the latest data from the CDC doesn't indicate a reprieve is coming anytime soon.
Stepping back, have you ever wondered how we did we get here?
The story begins in the 1990s and in many ways, it was the perfect storm of events: A segment of the population was in pain. There was a concerted effort to address it by the medical community, and a new drug that promised to help.
“I got my life back now. Now I can enjoy every day that I live. I can really enjoy myself. And before, each day was hell.”
“Since I have been on this new pain medication I have not missed one day of work.”
Those are clips from a promotional video Purdue Pharma distributed to physicians around the country about Oxycontin, a new controlled-release opioid pain medication the company aggressively marketed to providers for treating pain of non-cancer patients. The medication was designed to reduce pain fluctuations for patients, but much of the company's marketing materials misrepresented the risk for addiction and abuse as less than 1 percent.
Oxycontin seemed to be part of the solution to a problem the medical community had been facing. The Joint Commission, an agency responsible for certifying American healthcare organizations, had recently called on physicians to adequately treat patient pain, and some groups, including the Veterans Administration adopted pain as the fifth vital sign in patient assessments. After Oxycontin was introduced opioid prescriptions skyrocketed.
“Prior to that, we only saw these types of medications – opioids or morphine – prescribed or used in the setting for end of life pain treatment, cancer treatment; I mean only the most intense, usually under a hospital or hospice setting,” said Angela Stander, prescription drug overdose prevention coordinator for the Utah Department of Health. “And then in the mid 1990s is when it became FDA approved and it was under the impression that it was non-addictive and there were no dangers with them. So that's when we saw tons more prescribed and therefore tons more being addicted and a lot more overdose deaths.”
Stander said that both patients and prescribers need more education on the risks of prescription opioids. And physicians like David Anisman, the primary care medical director at the Farmington Health Center agree.
He recalls sitting in training sessions required for accreditation decades ago that were co-organized by Purdue Pharma. Anisman says this allowed the company to control the messaging about opioid risks and helped promulgate three myths to primary care physicians like himself.
“Number one that opioids are effective for chronic pain--there's no data to support that, there still isn't,” he said. “Secondly, that no dose is too high. So that as long as there is pain you should go up on the dosage, and third, that as long as you're using opioids to treat pain, you're not going to become addicted. Addicts are the people in the alleys with a needle in their arm. People who take pills you prescribe are not going to get addicted. Those are three of the central myths that I remember sitting through the training materials that we were required to take because it was part of belonging to an accredited organization. And that led to a lot inappropriate prescribing—a lot of the blindness to the nature of what we were prescribing.
“It's only been as the opiate crisis has gotten worse and we've come to realize that, for example, in the state of Utah, the majority of overdose deaths are not from heroin and they're not from synthetic opiates like fentanyl, they are from oxycodone which is Percocet and hydrocodone which is Lortab,” Anisman said. “Those are things we prescribe, primary care doctors, dentists, orthopedic surgeons, we're the ones doing that prescribing. So a real change not only for physicians, but for our patients because they learned from us, 'Oh you're in pain? Well, here's a pain med.' Every pain has to be treated, every pain has to go away. That's not realistic.”
Right now, where we are at, is it like turning a big ship around?
“Very much so,” Anisman said. “These habits both in the patient and prescriber population are not new, they are very well entrenched and it takes a lot of discussion, a lot of time and education to change those perspectives.”
But things are changing. In 2016, the CDC released new guidelines for clinicians detailing how opioids can be used more safely and effectively. And things are changing locally, too. The Utah legislature recently allocated more than half a million dollars to upgrade the state's controlled substance database, which compiles all of the prescriptions written in the state for controlled substances like opioids. This allows physicians to query a patient's record before writing a prescription and identify if suspicious behavior like doctor-shopping may be occurring.
“It compiles all of the prescriptions written in the state of Utah for any controlled substance, not just opiates, so you can query that and see what's been prescribed,” Anisman said. “The database also allows you to pull in data from selected surrounding states those that participate. So it does give you a great tool for seeing what's being prescribed. It doesn't of course tell you what they're getting from they're friends and family – and that happens a lot despite a lot of counseling, it doesn't tell you what they're buying off the street if that's what's going on.
"So you have to have other mechanisms and that includes things like pill counts, urine drug screens. Those are all part of our workflow to make sure that we are prescribing appropriately. We explain to our patients that this is just a standard of practice.”
Changes are happening within many of the state's largest healthcare providers as well. Intermountain Healthcare has trained more than 2,500 medical providers on the hazards of opioid misuse. In August, the organization announced a bold plan to reduce opioid prescriptions for acute pain cases by 40 percent across its hospitals and clinics. The goal is to prevent providers from over-prescribing opioids to patients who may not need them.
Dr. Anisman is a member of the Utah Coalition for Opioid Overdose Prevention and helped establish policies to better guide primary care providers on safer prescribing practices for opioids. He's also involved in an ongoing effort at the University of Utah to use data to reduce patients' risk of an opioid overdose. By tracking prescribingpatterns across the university the hope is that it will assist clinicians to identify their patients most a risk, those taking the highest dosages or taking combinations of medications that can be deadly.
But data alone won't solve Utah's opioid problem.
“The other side of the coin there is what patients expect,” Anisman said. “Patient perspective and expectations really drive the boat. I think in our society we have trained patients so that when they come to the doctor they should leave with a prescription for something. You have a cold? You get an antibiotic. You have pain? You get an opiate—not always right either.
"So we need to do more to educate the public about pain and the appropriate way and safe way to manage it. A lot of it comes back to not only changing the perception that there's a pill for every ill, but also that when we talk about pain we should be talking about function. And if you're not using those two words together, then something isn't right.”
Purdue Pharma could not be reached for comment for this story.
This seriesis brought to you in part by the Association for Utah Community Health, providing training and technical assistance to health centers and affiliates across Utah. More information available here.