In the late 1990s, pharmaceutical companies assured the medical community that the risk of patients becoming addicted to certain opioid pain medication was minuscule.
This contributed to healthcare providers prescribing large quantities of opioids, leading to extensive misuse of both prescription and nonprescription opioids and spurring what has become one of the most pressing public health crises in modern U.S. history.
During a June 18 webinar presented by Becker's Healthcare and sponsored by Collective Medical, Anne Zink, MD and medical director for emergency medicine at Mat-Su Regional Medical Center (MSRMC) in Matanuska-Suitna Borough, Alaska, outlined the origins and potential solutions to the opioid epidemic.
"For the first time in history aside from wars, the life expectancy of Americans has dropped," said Dr. Zink, referring to the CDC's Vital Signs: Overdose in Prescription Opioid Pain Relievers, United States, 1999-2008 report. "The medical community is the vector by which the epidemic has spread."
Dr. Zink noted that it is important to recognize opioid addiction is a disease, not a moral failing. As a disease, opioid addiction should be treated through science, collaboration and community.
How the opioid epidemic was born
Several factors contributed to the opioid epidemic, including:
- Payer coverage decisions to reimburse for opioids and not for other interventional treatments
- Pharmaceutical companies marketing opioids as safe
- Efforts to measure care quality with pain scores
- Low tolerance for pain and sickness in the healthcare community
- Financial stress among the patient population
- Increased exposure to legal and illegal opioids
"Every single day, approximately 130 people die from an overdose. About 82 percent of people who use heroin today started by initially using a prescription drug for legitimate medical reasons," said Dr. Zink, referring to Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use, published in 2017. "The U.S. has approximately 4.6 percent of the world's population but uses 80 percent of the world's opioids."
She added that although opioid dependence is a difficult disease to treat — it is not always predictable and varies highly in how it affects each user — it can be prevented.
Dr. Zink outlined four key components which MSRMC identified for tackling the opioid epidemic.
1. Recognize the problem, evaluate the data and set goals to lower prescribed opioids in emergency departments and raise awareness about other treatments.
2. Dr. Zink stressed the importance of educating clinicians about opioid addiction. MSRMC brought providers together in group meetings, drawing on community resources as well as personal and patient experiences to set goals for change.
3. She also highlighted the power that positive deviance can have in facilitating significant change in healthcare. Simply put, positive deviance is a collaborative approach to change in the healthcare community involving the cultural understanding of how we arrived at this opioid epidemic, why it is important to address and establishing what roles each group plays in the problem and the solution.
"The best laid policies are destroyed by a culture that doesn't support them and by changing the culture, you can create great policies that last forever," Dr. Zink said.
4. The fourth component for change is developing a culture of care collaboration and tools for change. It is pivotal to improve ways to connect with other healthcare providers and prescription drug monitoring programs to fully address patients' needs.
Alaska's emergency care providers brought physicians from the state together and created effective guidelines for prescribing opioids. Providers designed simple, evidence-based, flexible, provider-driven principles that were supported by hospital systems.
Understanding ACE and its ties to addiction
Dr. Zink highlighted the importance of understanding adverse childhood experiences (ACE) and their impact on a person’s addiction to prescription opioids. ACEs can be defined as prolonged exposure to stress at crucial periods in the formation of the brain. Such traumatic events include childhood abuse, childhood dysfunction, adult substance abuse and domestic violence.
Addiction spreads stronger and more rapidly in communities with high ACE scores, and 50 percent to 67 percent of drug problems were traced back to ACEs in the Adverse Childhood Experiences Study conducted in the mid-1990s.
Individuals with an ACE score of five are 7-10 times more likely to report drug use problems, addiction and parental use, while a score of six is associated with a lifespan reduction of 20 years. Resources such as the Substance Abuse and Mental Health Services Administration supports individuals with substance use disorder.
The organization's guidelines highlight the importance of understanding recovery, recognizing symptoms of trauma and realizing its effect on individuals, integrating trauma knowledge into policies and practices and seeking to avoid re-traumatization.
Additionally, providers can help build resiliency by addressing ACEs in patients and understanding the root of the disease.
Conclusion
Ultimately, Dr. Zink called for hospitals and policymakers to support positive deviance and harm reduction methods to combat the opioid epidemic. It is imperative to reduce barriers to care collaboration and address the underlying cause of addiction.
"As providers we can limit our opioid prescriptions when possible," Dr. Zink said. "We can find more meaningful ways of pain control, particularly with the more time consuming but more effective multimodal approaches. We can increase access to medication assisted treatment, disposal and reversals."
To learn more about Collective Medical, click here, and view the full webinar here.