Special to Medical Journal – Houston BY TED SHAW, President/CEO, Texas Hospital Association
Last month, the Centers for Disease Control and Prevention issued final guidance for the prescribing of opioid medications in outpatient settings for adults with chronic pain. The voluntary guidelines make recommendations for when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, followup, and discontinuation; and assessing risk and addressing harms of opioid use. The guidance followed several other actions by the federal government to address opioid abuse, including:
• almost unanimous passage by the U.S. Senate of the Comprehensive Addiction and Recovery Act;
• President Obama’s budget recommendation for $1 billion to expand access to opioid abuse treatment; and
• the U.S. Food and Drug Administration’s announcement that it would include “black-box” warnings on immediate-release opioids.
Opioids include legal prescription pain relievers, such as oxycodone, hydrocodone and methadone, and illegal heroin.
Texas lawmakers also have taken steps to address opioid abuse. With the passage of Senate Bill 1462 in the last legislative session, individuals suspected of having an opioid-related drug overdose will have expanded access to so-called opioid antagonists. These are medications designed to block the effects of opioids and reverse overdoses in most cases if given in time. The law, effective last September, allows opioid antagonists to be prescribed under a standing order, rather than to a named individual and explicitly grants distribution authority to a variety of entities and health care personnel.
All of these initiatives reflect the growing urgency among state and federal lawmakers and the health care community to address the national problem of opioid addiction, abuse, and overdose.
In Texas alone, total health care costs associated with opioid abuse approach $2 billion. And these are just health carerelated costs; that amount does not include the costs of lost wages and productivity, incarceration, social services, and other societal costs.
Since 1999, the amount of prescription opioids sold in the U.S. has nearly quadrupled as more products entered the market, health care providers became more sensitive to the needs of patients with chronic pain, and understanding increased of the physical and emotional consequences of not addressing chronic pain. Nationwide, in 2012, providers wrote 259 million prescriptions for opioid pain relievers. Yet, while the number of painrelief prescriptions increased, Americans did not report a corresponding decline in the amount of pain experienced.
What has increased, however, is the number of Americans dying from drug overdoses. According to the CDC, more people died from drug overdoses in 2014 than in any other year on record. The majority of these drug overdose deaths (more than six out of ten) involved an opioid. Nearly 80 Americans die every day from an opioid overdose. And this is a public health problem that affects every community in Texas and every age, socioeconomic and racial and ethnic group.
For Texas hospitals, the fight against opioid abuse takes many forms, including caring for those who have overdosed on opioids, those seeking to end their opioid addiction, and infants born to opioid-addicted mothers. It also includes being able to identify individuals who are relying on hospital ERs for medically unnecessary prescription opioid refills. Houston Methodist Hospital, for example, uses the Texas Department of Public Safety’s Prescription Access in Texas online database to identify individuals who may be abusing prescription medications. Through the DPS system, ER personnel have access to a list of pharmacies that have filled prescriptions for controlled substances for an individual. This allows health care providers to see not only prescription history but also if the patient has received prescriptions from multiple providers.
Hospitals clearly are on the front lines of opioid abuse treatment and prevention. But, a problem of this magnitude cannot be solved by hospitals alone. A multifaceted and concerted effort is needed that encompasses education, prevention, treatment, and rehabilitation and involves the entire health care community as well as the support of state and federal lawmakers.