Solving Opioid Addiction Crisis: No Silver Bullet

With the non-medical use of opioid drugs reaching epidemic levels in the United States, medical officials are discussing the many things needed to help stem the problem.

No silver bullet exists to solve the severe opioid drug addiction and overdose crisis gripping the region -- and nation.

Leading specialists in the field of addiction and opioid dependence, who are meeting in Philadelphia this week, say that's the stark reality of the issue.

But, experts say hope is not lost.

"Prescription opioids are effective as pain medications. If you get lower back pain or you get some kind of pancreatitis you are going to pray to God for some kind of opioid. And they will work. The problem is they also have an abuse liability," says Thomas McClellan, CEO of the Philadelphia-based non-profit Treatment Research Institute.

McClellan, who served as the Deputy Director of the White House Office of National Drug Control Policy (ONDCP), lost one son to addiction and has another in recovery, feels a perfect storm of over-prescribing, a lack of oversight and misuse by patients have led the nation to this crisis.

Opioid painkillers like oxycodone, hydrocodone and codeine are the most prescribed drugs in the United States – more than statins used to reduce cholesterol. Those drugs account for the overwhelming majority of drug overdose deaths nationwide, which, according to the Centers for Disease Control and Prevention, is now the leading cause of injury death. reported in October how Pennsylvania had 15.3 overdose deaths per 100,000 residents in 2010 with most of those deaths involved the use of prescription drugs – 14th in the nation, according to a report by Trust for America's Health. In Philadelphia, city officials recorded a 15-percent jump in deaths where prescription opioids like oxycodone and codeine were detected.

A severe spike of 63 overdoses during one month in Bensalem, Bucks County had the town's police chief calling the influx "unreal," leading him to divise crackdown plans.

In an interview before a town hall discussion on the topic at the American Association for the Treatment of Opioid Dependence, McClellan explained why a multi-faceted approach to the problem is the only way to curb this epidemic.

"You don’t have any alternatives. The only alternative is a non-steroidal anti-inflammatory; well it’s got liver toxicity and it’s not all that potent. There’s nothing between that and a very powerful opioid," he said. "This is one of those problems that society has to manage. You can’t do away with it. Not with 70 million older Americans who vote and are aging and needs them. You can’t ban them."

Training the Health Professions

With pain being a subjective feeling, doctors and other health professionals can never really know the true severity of a patient’s anguish. Pain scales, meant to measure the severity of the feeling, are rarely used properly by patients and non-painkiller forms of treatment like stretching, cognitive therapy and antidepressants are slow to provide results.

"A lot of these things relieve pain, but guess what, pills are quicker," he said. "Is your pain worse than his? How am I going to tell? So, the doctor has to rely on what the patient tells him."

So doctors prescribe the pills, but since many of these drugs gained widespread acceptance over the past decade, the physicians lack the training to understand the associated addiction.

"Doctors haven’t been trained to prescribed opioids properly. They prescribe too much. They don’t manage them. About 70-percent of all the overdose deaths occur within 48 hours after the first prescription or after the first refill," McClellan said.

Only one medical school in the United States, the University of Pennsylvania, has a required course on understanding and treating substance abuse, according to McClellan.

Dr. Jeannemarie Perrone, Director of Toxicology in the Hospital of the University of Pennsylvania’s Emergency Medicine Department and a professor in the School of Medicine, agrees that newer doctors are more lax about prescribing painkillers. She’s working to educate providers about reevaluating the pain scale.

"People come to the ER for pain all the time and we’re very attentive to all their vital signs including their pain score. So people equate that high score for pain as something that needs to be treated with our strongest pain medicines without remembering our strongest medicines have downsides and are risky," she said. She adds that patients suffering from ailments like the flu doesn't warrant a strong painkiller like percocet.

Both Perrone and McClellan recommend physicians also follow national pain guidelines set forth by the American Academy of Pain Medicine. They include having patients sign a usage contract and submit to a yearly toxicology screening test to confirm you’re taking the medicine and not taking other drugs before issuing a prescription.

Educating the Public

Doctors aren’t the only ones who need to better understand and address this problem. The non-medical use of the opioids starts outside the doctor’s examination room and the intent isn’t always to get high.

"Everyone feels comfortable because it’s a prescription drug. You wouldn’t give your roommate heroin because it’ll probably take care of their headache, but there’s a safety concept around it [prescription drugs], because it was prescribed by a doctor for pain and that somehow allows you to use it like a Motrin or Tylenol,” Perrone says.

But abuse does happen and it can begin with teens in your home. Research has found 70-percent of teens who abuse prescription drugs get them from family members and friends – many times taken from the medicine cabinet inside their home or the house of a family or friend.

"It has to be the joint responsibility of the patients to take medication as prescribed. Don’t give them to your sister, don’t leave them in your medicine cabinet, don’t take more than you need," McClellan said.

Experts urge adults to lock up their painkillers and properly dispose of medications when they’re done using them.

At the Drug Enforcement Agency’s (DEA) most recent drug take-back day on Oct. 26, citizens recycled more than half a million pounds of unused medications. In Pa., more than 38,000 pounds were returned.

Gary Tennis, Secretary of the Pa. Department of Drug and Alcohol Programs, says the state plans to install 250 permanent drop-off bins at local police stations across the state to offer patients a year-round option for keeping the pills from addicts.

Improve Oversight

Giving people suffering from the chronic illness of addiction access to better treatment is one way to cut back on opioid misuse -- as well as help the individual. Another is tighter regulation.

The U.S. Food and Drug Administration (FDA) announced last month they are close to petitioning the U.S. Drug Enforcement Agency (DEA) to reclassify hydrocodone – an opioid mixed with acetaminophen, the active ingredient in Tylenol – as a Schedule II drug. That change would make the drug, which is better known as Vicodin, harder to obtain and subject to more oversight.

"At the FDA meeting last January, data was presented…about how hydrocodone is abused in comparable forms to oxycodone, which we know is abused and that because it is abused it should be Schedule II," said Dr. Perrone, who is a member of the FDA advisory panel that recommended the change.

A hydrocodone reclassification would prohibit doctors from writing prescriptions with refills, according to the Pa. Department of Health. Patients would be required to go back to the doctor to get a new script for more pills. The classification change would not put a limit on the number of pills dispenses, however.

"In the risk of trying to approve the public health problem, the majority agreed the FDA should do this," she said.

A day after the recommendation, though, the FDA approved a new high-dose, long-acting hydrocodone drug that can easily become an addict’s source for a high. That approval drew ire from conference attendees and Perrone.

The addition of a statewide prescription monitoring program also provides accountability for the health care providers and helps cut down on patients who doctor-shop for drugs.

Such a database logs the filling of controlled substances in a state by a person’s name, the doctor who prescribed the drug and the pharmacy where it was filled. New Jersey has such a program, but Pennsylvania lacks a robust database.

A bill to build a more comprehensive system, called the Pharmaceutical Accountability Monitoring System (PAMS), recently passed the Pa. House and is currently in the state Senate. Tennis says he’s confident the bill will make it out of the statehouse and become law in the coming months.

Tennis has also called together a task force of doctors from around the state to discuss ways to bolster prescribing practices

"I just asked these doctors if they would come and speak with me and officials in four different departments in the state to talk about what they see is the best prescribing practices," he said.

Unintended Consequences?

No one will argue against trying to stem the crushing tide prescription painkiller abuse, but Tennis says lawmakers and the public need to be prepared to see a spike in heroin use when these systems are put into place.

“We know from other states, you can look at every state that has put these controls in place, there has been a growth,” he said.

Tennis says the state will need to ensure the treatment programs get the proper funding and support to try and divert those addicted to the opioids away from the cheaper, more prevalent heroin.

Contact Vince Lattanzio at 610.668.5532, or follow @VinceLattanzio on Twitter.

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