The Daily Dose • Wednesday, May 2

Tackling the Opioid Epidemic – A National Strategy

By Dr. Nawal Ragheb-Mueller, from the IARS 2018 Annual Meeting*

Today’s panelists at the IARS 2018 meeting presented several different angles on the national opioid epidemic. Dr. Richard Bonnie introduced the report from the National Academies of Sciences, Engineering, and Medicine and noted that this body is independent of the government. Established in 1863, the Academies assemble groups of experts to address pressing questions when called to do so by officials in government. Released in 2017, “Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use”, is a consensus report designed to update the public and policymakers on the rising tide of opioid use disorder which has reached unprecedented levels in the U.S.

Dr. Bonnie noted that the report was prepared by an extraordinary and broad group of scientists who were charged by the FDA with characterizing the epidemiology of the epidemic and asked to recommend strategies to stem this unparalleled tide. The report, authored in part by members of this IARS panel, noted that the opioid epidemic will not be controlled without deploying multiple policy tools in a comprehensive and sustained manner.

The crisis lies at the intersection of two public health challenges: helping tens of millions combat pain and stemming the tide of illicit use.

Narcotic prescriptions quadrupled between 1999 and 2010 in the wake of a massive promotional campaign for these drugs. Dr. Traci Green noted that as of 2015, two million Americans aged 12 and older have opioid use disorder (OUD) involving prescription opioids and nearly 600,000 have OUD involving heroin. Between 1999 and 2011, the annual number of overdose deaths from prescription opioids tripled. Drug overdose, she noted, is now the leading cause of unintentional injury and death in the U.S.

A critical feature of the opioid crisis – and of the report – is that the prescription and illicit opioid epidemics are intertwined. The three intertwined epidemics involve a) prescription and opioid drugs; b) heroin; and c) illicitly manufactured fentanyl and fentanyl analogues. The distressing social and human costs are estimated at $1 trillion dollars between 2001 and 2016 and the cost is climbing.

Dr. Green noted that in 2010 oxycontin was reformulated so that it could no longer be crushed and snorted. At this point, heroin use began to take off again.

Dr. David Clark, a pain medicine specialist and anesthesiologist, provided some statistics on OUD in the perioperative period. In the medical population, 25% of chronic pain patients on opioids misuse them. Ten percent develop an OUD and 1% transition to heroin. Risks factors include a history of substance use disorder, mental health problems, high doses of opioids /problematic prescribing, those using cannabis and benzodiazepines, as well as those who are younger, white, male and residing in rural areas.

The consequences of OUD in the perioperative period, Dr. Clark noted, are that these patients experience higher levels of post-op pain. This then requires higher levels of care and expertise. In turn, higher rates of treatment-related side effects and higher post-op pain scores result.

Clark provided some directions for needed research. How do we best detect OUD preoperatively and prepare the patient for surgery? Can we initiate OUD treatment in the immediate post-op period? How do we minimize iatrogenic initiation of chronic opioid use?

Panel member and pain specialist, Dr. Mark Schumacher noted that in an effort to reduce opioid demand, University of California, San Francisco School of Medicine established an NIH Center of Excellence in Pain Education. He also reviewed the CDC opioid prescribing guidelines and touched on efforts to reduce harms from opioids by reformulating some drugs to deter abuse. The outcome of this latter strategy has been rather mixed.

The panel members regrouped to take questions from the audience after their presentations. As they did so, Dr. Bonnie noted that regulation by the FDA with business as usual is “not going to cut it”. He advised that we will need more aggressive regulatory action than we have been used to and the comfort zone for regulatory officials will have to be stretched. This is the challenge the FDA now has. They have to expand their regulatory vision, which is a culture change, and we have to tackle the epidemic in a sustained fashion. It will require years of coordinated efforts of all stakeholders – patients, prescribers, state agencies, taxpayers, physicians, and public health specialists. The alternative is an increasing number of premature deaths and illness related to OUD that dramatically reduce quality of life.

*Coverage from the Panel session, A National Strategy to Reduce the Opioid Epidemic: A Report from the National Academies of Sciences, Engineering and Medicine