February 20, 2019, 08:42 am Michael Devitt – For family physicians who grapple with the effects of the opioid epidemic on a daily basis, there's new evidence that things may, unfortunately, get worse before they start to get better.
Although the number of opioid-related deaths may be decreasing in some states, overall, they continue to increase nationwide. The good news is that some research has shown that regulatory and legislative efforts introduced earlier this decade have succeeded in driving down prescription opioid dosage volume.
And, in turn, some evidence indicates that these efforts have contributed to a decline in mortality rates from prescription opioid overdose. The bad news, however, is that overdose deaths involving heroin and synthetic opioids have spiked during the same period.
Taking these trends into account, a team of researchers developed a mathematical model to project what the next few years of the opioid epidemic may look like.
Their results, published in JAMA Network Open earlier this month, show that current approaches that focus on misuse of prescription opioids will have, at best, a modest effect on the number of opioid overdose deaths in the near future, and suggest that the epidemic has to be addressed from multiple angles to make a real difference.
With data from the National Survey on Drug Use and Health, the CDC's Wide-Ranging Online Data for Epidemiologic Research (WONDER) database, and other published study data on heroin use, the researchers created the Opioid Policy Model, using it to gauge the effect of reducing the incidence of nonmedical prescription opioid use on opioid overdose deaths. First, they calibrated the model to reproduce observed trends in opioid misuse and opioid overdose deaths in the United States from 2002 to 2015, and then used it to project the same outcomes from 2016 to 2025.
Specifically, the researchers estimated the annual and cumulative number of opioid overdose deaths from 2016 to 2025, and whether those deaths would be caused by illicit or prescription opioids, under each of the following scenarios:
The research team repeated the analysis 1,000 times to ensure accuracy.
Under the no change scenario, the authors projected that the total number of opioid overdose deaths in the United States will continue to increase during each of the next few years, from 2015's total of slightly more than 33,000 to a high of almost 82,000 by 2025. Most of those deaths would be caused by illicit opioid use; the number of overdose deaths from prescription opioid use would actually decrease slightly to less than 14,000.
Altogether, the researchers projected that if prescription opioid misuse rates remain unchanged from 2015 onward, an estimated 700,400 people will die from opioid overdose. Eighty percent of those deaths would be attributed to illicit opioids such as heroin or fentanyl.
If, on the other hand, the incidence of prescription opioid misuse continued to decrease at a rate of 7.5 percent per year, the number of overdose deaths would peak at 75,400 in 2022 and remain relatively stable thereafter. Total estimated overdose deaths for the 10-year period between 2016 and 2025 would be about 674,000 -- a drop of 3.8 percent compared with the no change scenario.
By decreasing the incidence of prescription opioid misuse to 11.3 percent per year, estimated overdose deaths for the 10-year period would be 5.3 percent lower than in the no change scenario -- about 663,500 in all.
And even with no new incidence of prescription opioid misuse, the researchers estimated that slightly more than 579,000 overdose deaths would occur between 2016 and 2025, more than 86 percent of which would be from illicit opioid use.
The research team concluded that conditions are ripe for the opioid epidemic to worsen in the coming years and that current efforts to reduce misuse of prescription opioids are unlikely to have a significant effect on the number of opioid overdose deaths in the near future. What's needed, they wrote, is a multipronged approach that includes not only programs that monitor and restrict prescriptions, but one that also improves access to treatment, expands the number of interventions that reduce the harms associated with opioid use, and reduces exposure to illicit opioids.
David O'Gurek, M.D., a former chair of the AAFP Commission on Health of the Public and Science who practices in Philadelphia, agreed with some of the study's findings but also expressed concerns with some of the authors' methods.
"This is clearly a very complex issue, and readers should focus on the limitations section (of the study) to identify challenges of drawing too many conclusions based on the results of the study," he told AAFP News.
O'Gurek did agree, however, with the overall suggestion that more needs to be done to make any real headway against the epidemic.
"Public health problems require comprehensive public health solutions," he said. "An overhaul of our approach, focusing less on health care and looking more to advance both the individual and community and population health, are necessary."
Such an approach, O'Gurek noted, includes looking beyond current systems of harm reduction and treatment to forge innovative prevention efforts that include a "health in all policies" approach to address social determinants of health and build optimal healing environments that are trauma-informed.
That said, O'Gurek acknowledged that when it comes to caring for patients who walk through the door, like many family physicians, he's doing the best he can with the tools and resources available to him. He learned how to administer buprenorphine during his residency and currently provides office-based opioid treatment in his practice. From that perspective, he shared some things that work -- and some that don't.
Although the U.S. Preventive Services Task Force has said evidence is insufficient to support population-based screening for illicit drug use and nonmedical use of prescription drugs in adolescents and adults, O'Gurek suggests that given the current environment, screening for opioid use disorder (OUD) should be considered.
Although tools to specifically identify OUD remain elusive, there are simple screening tests for substance use disorders that family physicians can use as a starting point for further evaluation. For family physicians who choose the screening route, O'Gurek said it is "critical" that they also have a system in place that allows for easy access to treatment of OUD.
If a family physician suspects OUD in a patient, O'Gurek encourages the physician to have an open and nonjudgmental conversation with the patient, which can positively influence a patient's decision to seek treatment.
"It is important to note that patients with substance use disorder often suffer from significant stigma and often have had negative experiences with the health care system in the past," he said. "Altering this course can facilitate incredible rapport, leading to interest in treatment."
Regarding treatment, it's key to tailor the process to each patient, O'Gurek stated. Although opioids have a place in treating chronic pain, he emphasized the importance of appropriate opioid stewardship.
O'Gurek also noted that although a number of guidelines on treating chronic pain with opioids have been developed, recommendations often are made with little supporting evidence and without a clear sense of the benefits -- and harms -- associated with those recommendations. He advised FPs to consult the AAFP's chronic pain management toolkit to help them develop protocols and processes for managing chronic pain.
"What doesn't work is clearly a one-size-fits-all approach to either care of chronic pain or OUD," O'Gurek said. "Family physicians understand that guidelines are guidelines, and care must be individualized and built on a strong patient-doctor relationship. Working together toward health cannot simply be dictated by some regulation or guideline that specifies things can be done in a vacuum."
Given the scope of the opioid epidemic, O'Gurek said there are three things family physicians can do that will have a significant impact.
First, FPs can become more culturally proficient in caring for patients with substance use disorder. "This starts with the language that we use," he explained. Terms such as "addict" or "drug seeker" should be avoided. Instead, family physicians should use person-first language such as "a person with a substance use disorder" or "a person who injects drugs."
"An internal change in our approach and our language can affect our staff's approach and create a culture of acceptance within practice settings," O'Gurek said.
Second, family physicians must be aware of the impact of trauma on patients, especially those who have experienced an adverse childhood event such as physical or emotional abuse or neglect. Approaching a patient as someone who has had something happen to them, rather than as someone who has something wrong with them, helps FPs provide care nonjudgmentally and can allow them to get at the root causes of a patient's pain or disorder.
Third, O'Gurek recommended that family physicians obtain a Drug Addiction Treatment Act (DATA) waiver so they can prescribe buprenorphine and integrate pharmacologic treatment for OUD into their practices.
O'Gurek also encouraged all family physicians to review the AAFP's position paper on chronic pain management and opioid misuse, which contains a list of actions FPs can take at the physician, practice, community and advocacy levels.
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