Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

Abstract

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.

Pain management after dental extractions – non-opioid combination analgesics minimize opioid use for acute dental pain

“…No opioids were prescribed for patients with dental pain in the past 12-months in HDUC. Considering that about 1,800 patients received prescriptions of more than 20,000 pills of opioids annually in this clinic alone before we introduced our opioid reduction initiatives 22 , reducing the reliance on opioids for acute dental pain is particularly salient in light of a persistent OUD crisis 2,38,39 . Population-based cohort studies found that 2 - 7% of the patients receiving a dental opioid prescription would develop new and persist use of opioids within one year 9-11 .…”

The need to improve opioid prescribing and data collection in patients undergoing orthopaedic surgery

“…This can be partially attributed to `big pharma´promoting the use of the World Health Organization (WHO) analgesic ladder for cancer pain for the management of types of pain that historically would be managed by simple analgesics and non-pharmacological strategies [1]. Despite the belief initially purported by the drug companies that prescribed opioids are safe, they are actually dangerous and cause death and harm by overdose and other adverse effects [2][3][4]. It is now well recognised that the global opioid crisis that started in the USA in the 1990s and directly contributed to over 100,000 deaths worldwide in 2017, originated with the aggressive marketing and subsequent misuse of prescription opioids [2,3].…”

“…Despite the belief initially purported by the drug companies that prescribed opioids are safe, they are actually dangerous and cause death and harm by overdose and other adverse effects [2][3][4]. It is now well recognised that the global opioid crisis that started in the USA in the 1990s and directly contributed to over 100,000 deaths worldwide in 2017, originated with the aggressive marketing and subsequent misuse of prescription opioids [2,3]. The economic and societal effects of the opioid crisis on the USA economy are staggering, with an estimated 450,000 opioid-related deaths over the past two decades, and an annual financial cost to the economy of $700 billion to $1 trillion, which equates to 3.4% of the USA gross domestic product [2].…”

“…It is now well recognised that the global opioid crisis that started in the USA in the 1990s and directly contributed to over 100,000 deaths worldwide in 2017, originated with the aggressive marketing and subsequent misuse of prescription opioids [2,3]. The economic and societal effects of the opioid crisis on the USA economy are staggering, with an estimated 450,000 opioid-related deaths over the past two decades, and an annual financial cost to the economy of $700 billion to $1 trillion, which equates to 3.4% of the USA gross domestic product [2]. The lethality of opioids is not just limited to deaths attributed to overdose.…”

Factors Associated with Fatal Overdoses After a Prescription for Pain

“…That works out to roughly one opioid-related death every seven minutes. (See Kharasch et al, 2022. )…”