Health care’s role in escalating America’s opioid crisis

April 16, 2018 / By Steve Delaronde

There were nearly 64,000 drug overdose deaths in the United States in 2016.  Opioids account for two-thirds of those deaths. The number of overdose deaths involving opioids is five times higher than it was in 1999. This dramatic increase has put opioids on the front page of America’s newspapers and resulted in HHS Secretary Alex Azar identifying the opioid crisis as one of his four top priorities.

Effectively addressing the opioid crisis involves a better understanding of the different types of opioids, who is using them, how they are getting them, and how to prevent the harms associated with short-term and long-term use. 

The Centers for Disease Control has identified three waves associated with a rise in opioid-related deaths. 

1. The first wave of the opioid crisis began in the 1990s when opioid prescription rates began to increase. The introduction of Oxycontin, an extended release form of oxycodone, in 1995 and its promotion by manufacturer, Purdue Pharma, helped accelerate the trend of prescribing opioids for chronic, non-cancer related pain. 

Opioid use for hospitalized patients with acute pain, including nonsurgical hospital admissions also became more prevalent. However, prescribing rates for opioids peaked in 2012 and fell to a 10-year low in 2016. Unfortunately, these lower prescribing rates are not occurring uniformly throughout the country, leaving some counties with prescribing rates seven times higher than the national average.

2. The second wave of the opioid crisis began in 2010 with a rise in heroin overdose deaths. This occurred around the same time that deaths involving prescription opioid pain relievers began decelerating in 2011.  Heroin-related deaths now account for nearly one-quarter of all drug overdose deaths. There has been a five-fold increase in the rate of heroin-related deaths from 2010 to 2016.

3. The third, and most recent, wave of the opioid crisis began in 2013 with illicitly manufactured fentanyl (IMF). Fentanyl is a prescription drug typically used for treating advanced cancer pain, but it’s high potency has led to illegal production and distribution. This has resulted in double the number of synthetic-opioid related deaths from 2015 to 2016 and is now linked to more opioid deaths than heroin.

Hospitals, physicians and drug manufacturers certainly play a role in the escalation of the opioid crisis over the past five years. While opioid prescribing rates may be at a ten-year low, there is still wide variation in prescribing patterns across physicians, geographic regions, medical conditions and facility settings. 

Opioids are typically prescribed for short-term use. The antecedents to long-term use include multiple prescription fills in the first month of use, the use of long-acting opioids as initial therapy, and the initial prescribing of high cumulative doses. Efforts must be made to reduce the initial prescribing of opioids, as well as identify and address the risks of developing long-term use and addiction.

Finally, prescription drug misuse does not only occur with opioids. The other two classes of prescription drugs most likely to be misused are central nervous system (CNS) depressants and stimulants.  Amphetamine use resulted in the largest proportional increase in emergency department visits involving the nonmedical use of a prescription drug from 2,303 visits in 2004 to 17,272 in 2011.  The identification of risk factors for prescription drug misuse, the development of predictive models, the implementation of effective approaches to prevention and treatment, as well as understanding the role of prescribers, drug manufacturers and patients themselves are all necessary for healthcare organizations be part of the solution and not be viewed as part of the problem.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.