Dr. Suryadevara is Assistant Professor, Department of Psychiatry, University of Florida, Gainesville, FL, and Assistant Professor, North Florida/South Georgia VAMC, Psychiatry, Gainesville, FL. Dr. Holbert is Assistant Professor, Department of Psychiatry, University of Florida, and Dr. Averbuch is Associate Professor, Department of Psychiatry, University of Florida.
The United States is currently in the midst of an opioid epidemic. The numbers are staggering: in 2016 there were 78 deaths per day from drug overdose, two-thirds of which involved opioids. Since 1999, deaths from opioid prescriptions have more than quadrupled.1
As is often the case, the origins of this epidemic are multifactorial. Some overprescribing can be traced back to the health care profession’s efforts to recognize pain as the fifth vital sign, which compelled physicians to treat more aggressively. Some pharmaceutical companies may have also contributed to the problem through aggressive marketing of prescription opioids without proper emphasis on their addictive potential. Regardless of the cause, the problem is pervasive, affecting all socioeconomic groups and spheres of society.
While opioid use disorders are more common in younger patients, prevalence among the elderly is growing, and misuse poses unique risks in the geriatric population. From 1996 through 2010, the number of opioid prescriptions provided to older patients increased 9-fold. More alarming, 35% of patients aged older than 50 years with chronic pain reported misuse of their opioid prescriptions in the past 30 days.2,3 The hospitalization rate for geriatric misuse of opioids has quintupled in the past 20 years alone.4 Given the scope of the problem, federal and state governments have begun to implement new guidelines in prescribing opioids, but tighter regulations may intrude on individualized patient care and the benefits of opioid therapy in some patients. Whether these new policies are the best strategies remains to be seen.
Avoiding iatrogenic addictions
Avoidance of iatrogenic addictions may be the first step in addressing the epidemic. Some situations are more straightforward. Most clinicians can distinguish which of the following fictional cases is an inappropriate use of opioids: a 78-year-old in hospice care for terminal lung cancer; a 65-year-old who underwent major surgery that morning; or a 68-year-old with a history of depression, anxiety, and chronic pain, and a urine drug screen positive for cocaine, opioids, and benzodiazepines (prescribed). Contrast that with more complex, typical clinical scenarios in which the distinction can be a real challenge.
Mr. X is a 66-year-old under hospice care for hepatocellular carcinoma, with a comorbid severe alcohol use disorder. Opioids were prescribed until his urine drug screen came back positive for marijuana and cocaine. Two days after opioid therapy was stopped, the patient was found dead due to a self-inflicted gunshot wound. Pain was determined to be a major contributing factor. This case highlights the importance of understanding the delicate balance between risks and benefits when prescribing opioids, and the unique role psychiatrists play in their use.
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