The Opioid Crisis: How Can We Do Better?

October 27, 2018

ORLANDO, Fla.—Physicians in the United States continue to prescribe too many opioids for their patients, despite years of increased focus on the country’s deadly opioid epidemic, Anna Lembke, MD, told attendees at Psych Congress 2018.

Anna Lembke, MD
    Anna Lembke, MD 

“Although the media has appropriately focused on illicit opioids, we continue to have a very serious prescription opioid death related problem,” said Dr. Lembke, Associate Professor of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, California.

“Today, when you ask heroin-addicted persons ‘what was  the first opioid you ever used?’ more than two-thirds will say ‘I started out with a prescription opioid.’ ”

Dr. Lembke is the author of the influential 2016 bestseller Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.

Q&A With Dr. Lembke: Hidden Forces Behind the US Prescription Drug Epidemic

At her Psych Congress Featured Session, she presented a brief history of opioid use in the United States in recent decades. Prior to 1980, doctors were reluctant to prescribe opioids because they were scared patients would get addicted to them, she said. At the same time, there was a recognition that not enough was being done for patients suffering from chronic pain.

The idea of prescribing opioids for more patients with intractable pain came from well-intentioned doctors, including palliative care and pain doctors, Dr. Lembke said. “It was really a good idea at its initial inception,” she added.

However, by the end of the 1990s, “doctors were dispensing opioids like vending machines to pretty much anybody who came in and said I have pain,” she said.

There is no doubt that today’s opioid epidemic is related to overprescribing, the presenter said. The problem stretches across all medical specialties, and does not involve only so-called “pill mill doctors,” she noted.

“This is an epidemic in which this enormous paradigm shift caused us all to change our prescribing around opioids,” she explained. “This epidemic is not driven by a small subset of prolific prescribers. Across the board all disciplines are prescribing more opioids.”

THE SECOND WAVE

The United States today is in the second wave of the epidemic, the presenter said, noting “what started out primarily as a prescription drug misuse/addiction/overdose problem has now given way to an illicit opioid problem.” The number of deaths from illicit opioids, particularly heroin laced with fentanyl, has surged in the last 2 to 5 years, she said.

A majority of people addicted to heroin today started their opioid use with a prescription opioid. In contrast, for most people addicted to heroin in the 1970s, heroin was the first opioid they used.

Although opioid prescribing has decreased since it peaked in 2012, “we’re still prescribing way more than we should be prescribing,” Dr. Lembke said. Data released by the Centers for Disease Control and Prevention in 2016 showed a concentration of very heavy opioid prescribing in some Southeast states, and within some states across the country where the number of opioid prescriptions had gone down, it remained high in some counties.

Dr. Lembke emphasized the ongoing role of health care providers in the opioid epidemic with 2016 data showing that 35% of people misusing opioids got the drugs from a single prescriber. Another 53% got them from a friend or relative, most of whom had been prescribed the drugs. Just 6% got them from a drug dealer.

She also suggested the country is in the midst of a hidden benzodiazepine epidemic, noting there was a 7-fold increase in overdoses related to the drug class from 1999 to 2015. Two-thirds of the deaths also involved an opioid, “but benzodiazepines by themselves can kill and there has been relatively zero focus on the problem of benzodiazepine overprescribing,” the speaker said.

UNSEEN FORCES

Dr. Lembke suggested to attendees that the opioid epidemic is the “canary in the coal mine for a faltering health care system.”

“I believe that opioids have become the solution not to patients’ problems but to doctors’ problems,” she said.

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