Louisville Medicine Volume 65, Issue 8 - Page 13

FEATURE toring “the fifth vital sign” encouraged physicians to make their patients free of pain. In those days the prescribing of hydrocodone with acetaminophen was the norm. For a number of companies in the manufacturing sector, the use of Vicodin was the highest pre- scribed drug by volume of pills. Vicodin was first introduced into the market by Abbott Labs in 1984. Eleven years later, OxyContin was marketed by Purdue Lab as its proprietary version of oxycodone. The combination of prescribing narcotic meds to keep people free of pain and aggressive marketing of these drugs by pharmaceutical companies created a high demand. But not all patients prescribed narcotics become addicted. Esti- mates from various sources place between one percent and 25 per- cent of opioid addicted people note that they started their addiction with physician prescriptions for acute pain. The use of marijuana as a “gateway” to opioid use has been studied. Marijuana has been shown to enhance the addiction to caffeine and to nicotine. There is the assumption that it would also enhance the tendency to use “hard drugs.” The National Institutes of Health has been reviewing the evidence but has yet been unable to indicate whether marijuana use leads to a tendency for use of opioids by itself. Of the 97 million people in the U.S. who took a prescription nar- cotic, 12 million did so without a legitimate prescription. Diversion of prescribed opioids is a major issue. This is accentuated by the liberal prescribing of physicians and dentists. Highmark Blue Cross found that following a dental visit where pain killers were prescribed, that the average prescription was for a 28-day supply. Most dental patients do not need narcotics after the first few days. This leads to a large volume of unused pills. In a study of 1.2 million Medicare beneficiaries, who received at least two narcotic prescriptions in 2011, that 34 percent received those from two physicians, 14 percent from three providers, and 12 percent from four or more physicians. Given the difficulty in sharing information on prescribing in many states, this is not surprising. Kentucky was among the early states to adopt the communication platform, KASPER, which allows doctors to know the prescribing of other colleagues. There is, of course, the distinction that needs to be made between tolerance of a prescribed opioid that requires a higher dose to achieve the same level of pain relief, and physical dependence that would require a drug taper to avoid withdrawal symptoms. Addiction is an independent issue and not as predictable as either tolerance or physical dependence. Only a fraction of people prescribed opioids do become addicted, but that number is quite significant in a so- cietal context. As people become dependent or addicted to prescribed narcotics, the cost and access barriers may become significant. Heroin and other street drugs, including non-prescribed fentanyl, become less expensive alternatives. So what are the strategies to curb this epidemic? The current na- tional strategies are focused on reducing access to higher-than-need- ed volumes of prescribed narcotics, initiation of more drug treatment programs, and public access to life-saving naloxone: 1. REDUCING ACCESS TO HIGHER-THAN-NEEDED VOLUMES OF PRESCRIBED NARCOTICS. This strategy is to reduce the number of people becoming addicted to prescription drugs and to reduce diversion. It will not solve the issue of those who are currently addicted. Indeed there is concern that those addicted to prescribed narcotics may turn to street drugs if the source of their addiction is restricted. This complex set of physician-managed strategic goals demands a multi-stage approach by doctors who write narcotic prescriptions, including: » » Assessment of need: as a profession we need to recognize that people in acute pain should be treated but be limited in the supple to “just enough” rather than the insurance covered 30-day supply. » » Verification that there is no other active prescription: drug monitoring programs such as KASPER can verify the number of active prescriptions and the pattern of use. » » Assessment of addiction potential: use office-based screen- ing tools to assess potential addiction such as the Opioid Risk Tool or the Screener and Opioid Assessment for Patients with Pain. » » Verification of use: the use of urine drug screening for patients at risk can indicate if the patient is using only the drug prescribed. If used, such tests need to be randomly performed and part of a contract. » » Develop a doctor-patient contract for management of prescribed narcotic. Such a contract becomes the written basis for managing expectations. 2. INITIATION OF DRUG TREATMENT PROGRAMS For some individuals, it is appropriate to become “clean” and discontinue use. As with other addictions, treatment programs focused on initial medical treatment for detoxification and physical withdrawal that is coordinated with management of the addiction. This can range from Narcotics Anonymous based programs (in Louisville: www.nalouisville.net) to long-range treatment programs. Psychology Today has a link to treatmen t facilities in Louisville (https://treatment.psychologytoday.com/ rms/prof_results.php?city=Louisville&state=KY&spec=232) The City of Louisville Office of Addiction Services has a listing of its services on its web page (https://louisvilleky.gov/govern- ment/health-wellness/office-addiction-services) For other patients, maintenance rather than cure is the pre- ferred treatment. The two principal maintenance programs involve either methadone or suboxone. Both now require a specific license. Louisville has two methadone clinics, both of which use the liquid form and require the addict to come on a daily basis. Methadone can prevent withdrawal symptoms JANUARY 2018 11