Pain Management and the Opioid Epidemic

Abstract

Years of sustained, coordinated, and vigilant effort will be required to contain the present opioid epidemic and ameliorate its harmful effects on society. At least 2 million people have an opioid use disorder (OUD) involving prescription opioids, and almost 600,000 have an OUD associated with heroin (HHS, 2016). These numbers are likely to increase in the coming years, regardless of what policies are put in place. Follow-up studies of individuals receiving treatment for OUD involving heroin (e.g., Hser et al., 2001) find very high rates of premature mortality (in the neighborhood of one-third) due to overdose or other complications of the disorder. Thus, even if the nation ramps up treatment availability substantially and immediately, death rates will climb and quality of life will be dramatically reduced for many people for years to come. Likewise, the continued progression of still more people from prescription opioid use to OUD will demand sustained and coordinated effort to establish and implement the scientifically grounded policies and clinical practices necessary to reshape prescribing practices and reduce the occurrence of new cases of prescription opioid-induced OUD. 1 What should be done to contain the opioid epidemic and to prevent new cases of iatrogenic addiction and associated overdose, death, and other harms? The purpose of this chapter is to review available evidence on strategies that have been used to address the problems of opioid misuse, OUD, 1 Vigilance will also be needed to reduce the risk of similar problems in the future with other classes of medications for which there exists demand for clinical uses other than the indicated conditions and/or active black markets for their resale. 269RCTs, however, are rare for policies that require implementation at the level of an entire jurisdiction, nor are they ethically permissible in many policy contexts. In the absence of RCTs, other sources of evidence are needed to estimate the counterfactual outcome distribution under different strategies. One such source of evidence is the collection of data on individuals who happen to receive the strategies of interest as part of their routine care, often from electronic health records. The so-called observational analyses based on such data are attempts to emulate the RCT that cannot be conducted (the target trial). In these observational analyses, however, the comparability of the groups receiving each strategy is not guaranteed. In the real world, for example, the restricted opioid prescription policy might more likely be applied to individuals visiting providers in urban health care settings who also received other interventions to reduce the risk of addiction. As a result, a direct comparison of the outcome distribution between those who received each strategy would be confounded by the concomitant interventions.Observational analyses attempt to eliminate bias due to confounding by adjusting for all measured prognostic factors that are distributed differentially between the groups. For example, the ...

Retention of Student Pharmacists’ Knowledge and Skills regarding Overdose Management with Naloxone

“…36,37 This is especially important since pharmacy students possess higher than average prevalence of risky substance use behaviors 38 and are an essential component of overdose prevention and response. 18,39 Surveys of practicing pharmacists have shown that despite successful programs on overdose education, 40 pharmacists continue to lack confidence and willingness to prescribe and dispense naloxone. 41,42 One way to easily integrate training with an active learning component is to pair naloxone training with basic life support training a requirement of nearly all health professional schools.…”

“…Therefore, student pharmacists should be trained to identify these patients at risk and be able to provide naloxone education and training. 18 This study seeks to assess differences in the retention of knowledge (objective data) and impressions of overdose prevention efforts (subjective data) between student pharmacists who received the content delivered by a 50-minute lecture only and those who received the same lecture and completed an objective structured clinical examination (OSCE) of interactive counseling with standardized patient actors. Overdose education and naloxone training was recently implemented into the required curriculum of the College of Pharmacy at the University of Rhode Island in an effort to better prepare student pharmacists to identify intervention opportunities with at-risk patients.…”

Overcoming overuse: the way forward is not standing still—an essay by Steven Woloshin and Lisa M Schwartz

“…The tragic example of the opioid epidemic shows industry’s harmful role in fuelling overuse through misleading marketing, biased medical education programmes, kickbacks, and manipulation of professional and patient organisations 12. These efforts transformed prescribing: opioids became drugs of choice for chronic non-cancer pain despite the lack of evidence of benefit.…”

Evidence That Social-Economic Factors Play an Important Role in Drug Overdose Deaths

“…According to one, widely repeated account, the problem lies largely with pharmaceutical companies who have recklessly marketed opioids. Journalists and researchers tell and retell the story of Purdue Pharma's aggressive and highly successful marketing campaign to persuade physicians to prescribe Oxycontin to their chronic pain patients (e.g., Meier, 2018;Quinones, 2017;Zhang, 2017). In support of this explanation, American physicians were prescribing three times more opioids in 2012 than in 2001 (our calculations, see Results).…”