one of the most important obligations of a physician is to treat pain adequately. Recently, the treatment of chronic pain has expanded into the primary care setting (Reid MC, 2002).  Many primary care physicians are unsure about how to efficiently and safely prescribe opioids for the treatment of pain (Savage SR, 2003).  Moreover, the treatment of pain is complex because many times, pain disorders are associated with a variety of psychiatric conditions (Chelminski PR, 2005).

According to the National Institute of Health (NIH), nonmedical use of opioids have “more than doubled among adults” between 2001 and 2013.  In fact, in a study from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), approximately 4.1 percent (10 million) of the adult population used opioid medications between 2012 and 2013.  This is higher than the percentage of use between 2001-2002, which was 1.8 percent.

In the last decade, the level of opioid use has increased to alarming levels (Survey on Drug Use and Health, 2006). 

As per Dr. Nora D. Volkow, MD, the director of the National Institute on Drug Abuse (NIDA), “the increasing misuse of prescription opioid pain relievers poses a myriad of serious public health consequences”. These include “increases in opioid use disorders and related fatalities from overdoses, as well as the rising incidence of newborns who experience neonatal abstinence syndrome.  In some instances, prescription opioid misuse can progress to intravenous heroin use with consequent increases in risk for HIV, Hepatitis C and other infections among individuals sharing needles” (CITATION).  In addition, based on the Substance Abuse and Mental Health Services Administration’s Drug Abuse Warning Network, there has been a 153 percent increase in emergency department visits from 2004 to 2011.

In an analysis conducted in 2011 by the NIH, more than half of the patients who received prescription medications for pain in 2009 had filled another pain prescription 30 days earlier. 

The study also found that 12% of opioids, which were prescribed to teens aged 10-29 was mostly by dentists, and nearly 46% of prescriptions were for patients 40-59 and were mostly prescribed by primary physicians. According to the Center for Disease Control (CDC), prescription opioid overdose is now the 2nd leading cause of accidental death in the US, “killing more than heroin and cocaine combined” and therefore has become a major public health concern.

 

Opioid Epidemic in Florida

Another important aspect of opioid abuse is that it is not limited to drug abusers alone as previously mentioned.  

For example, the 2012-2013 NESARC-III data, has found a link between type of opioid used and mental health disorders such as depression, bipolar, schizotypal, antisocial personality disorder and post-traumatic stress disorder.  It turns out that major depressive disorder (MDD) is associated with nonmedical prescription opioid use, whereas bipolar type I disorder is associated with prescription opioid use.  Both non-medical prescription opioid and prescription opioid use have increased from 2001 to 2013 between 161 percent and 125 percent respectively.  According to the authors of the study, this may have been because of the lower dosages, people may believe it to be less risky as it is now legal, and lack of knowledge about the addictive.

Clearly there are many contributors to opioid use.  In fact, alcohol abuse has been found to correlate strongly with opioid addiction, and this poses a danger to all users.  Combining alcohol and opioids is lethal.  Moreover, prescription opioid abuse does not only affect the patients, in 2001 over prescription was estimated to be $8.6 million.

This included, health care, criminal expenditures as well as workplace. 

 According to Strassels SA who wrote on the Economic burden of prescription opioid misuse and abuse, the economic burden of those who abused opioid prescriptions were nearly more than five times the costs of non-abusers.

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An article on the Economic burden of prescription opioid use, suggested intervening on three different aspects: 1) provider education, 2) patient screening and 3) use of technology.

Provider Education is an important aspect of prescribing any medication, and more importantly opioids.  Many patients may not know the addictive properties of opioids.  In addition, adequate history taking is crucial.  Many patients that abuse alcohol are at an increased risk of drug abuse, and the combination of alcohol with opioids can be fatal (Gudin JA, 2014).  Moreover, studies have shown that many primary care physicians are not confident when prescribing pain medications to manage chronic pain (Pearson, Amy CS 2017).  In another study, many physicians wished they had received proper training during their medical student years so they could begin prescribing pain medications more comfortably and with more confidence (Khidir, Hazar 2016).

 In Massachusetts, their medical school programs have devised special educational strategies to help their students identify patients at risk of opioid abuse, how to treat pain in patients identified as ‘at high risk’, and how to manage substance use disorders (O’Rourke J, 2016).

As to patient screening, substance abuse questions are common practice by all physicians when taking histories.   

 According to Gudin et al, routine toxicology testing should also be considered.  Especially by pain management physicians and primary care physicians who routinely prescribe opioids and benzodiazepines for chronic pain. In fact, drug screening is done to monitor compliance and misuse (Milone, 2012), and this is something that should definitely be extended to patients who may be prescribed opioids for pain management. 

This I believe helped in preventing over-prescription of opioids and especially to those who misused them.  Based on the information above, I recommend the following three policies to address the rising opioid epidemic here in Florida.  The recommendations were constructed using the following criteria: 1) Enhancing the likelihood of acceptance by voters in Florida. 2) Be relatively low cost to implement and 3) Have the largest impact on countering the opioid epidemic.

My recommendations are as follows:

First, proper training on how to treat pain must begin during medical school.  Although current practicing physicians also need adequate guidance, the largest effects for the future is to start at the medical school level.  This will lead to adequate knowledge about pain management in the graduating classes, and a higher level of competency when it comes to treating pain.  Giving doctors confidence on their management of patients with chronic pain conditions will prevent over prescriptions, allow for identification of patients at risk of addiction, and proper training in managing patients with psychiatric conditions in combination with pain disorders.  I strongly believe that pain management should be a required rotation for medical students.Along with this added education on pain management, there should also be education about proper reading of lab tests, toxicology screenings and possible limitations to allow physicians to make decisions on patient care.  This should be quite easy for Floridians to vote on, as it would implement change in an already present system.  In addition, there would be no added cost to the schools or hospitals.  On the contrary, they would be creating well-informed doctors who will be better able to combat the opioid crisis that is currently worsening.  

Second, any patients who have psychiatric conditions or alcohol addictions would benefit immensely from routine toxicology screening as proposed by Massachusetts. In doing this, you guarantee adequate monitoring of patients taking opioids as well as compliance.  This would include lack of compliance, as well as over ingestion of the opioids prescribed or ingestion of non-prescribed medications.  Maintaining what is called therapeutic levels of pain medications are very important when managing chronic conditions, and chronic pain is an area of practice that may also benefit from this.

Although there are certain limitations to this practice such as proper readings of the results, false positives, and false negatives, studies show that both the long and short term effects of routine toxicology screening would improve health care and patient care (Vadivelu, 2010).

 Third, the use of technology would be immensely beneficial to the increasing public health concern.  This would allow an integration of nationwide prescriptions of opioids and would allow proper management.  Initial implementation would no doubt present multiple issues.  These include training on how to use the program.  Also, not all the hospitals nationwide use the same software for patient care, so communication between systems is nearly impossible. Another limitation is that implementing something nationwide is not an easy task since it requires working together and agreeing on the end result for it to actually function.  Although complicated, the benefits of having a opioid prescription tracking program are immense. 

To begin, it would need to be local, or county based.

Adopting a similar software of the one used in NYC should be considered.  Overall, learning how to effectively and safely prescribe opioids are the most important aspects of this current epidemic.

Therefore, interventions at medical school, hospital and community levels are necessary to not only educate everyone about the adverse effects of misuse of opioids, but also to allow continued care of prescriptions so that the patients who really need them, can have them.

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