Estimated that approximately 10 million new patients have been added to the health care rolls in 2014; about 10 percent of them are estimated to be substance abusers. One of the unintended consequences of the increased access to the medical system by substance abusers will likely be inadvertent mis-prescribing of opioids by physicians unfamiliar with addiction assessment. This will escalate the legal debate on how best to respond to the growing drug problem in the U.S., which is surfacing in many different arenas.
The U.S. has 5 percent of the world’s population but consumes 80 percent of the world’s prescription opioids. The hotspots for the spread of the drug epidemic are multiple across the U.S., surfacing in areas where pain medications are prescribed excessively and patients transition to low cost, high potency heroin. Preventing prescription opioid deaths has become a public health priority (Jones et al. 2014), and there is a trend toward upscheduling of specific narcotics, e.g. moving hydrocodone to Schedule II, in order to lessen their use. This provides only a limited solution; improved education and training of medical practitioners on the complexities of pain and addiction is also necessary.
Several factors contribute to this rise in opioid prescribing. Many more opioids are available for treating pain than have ever been previously available. More opioids are being prescribed for long-term pain rather than for only acute pain. In combination with the new medications, and as awareness of pain’s impact on an individual’s quality of life and ability to function has grown, growing numbers of physicians are prescribing opioid medications. These drugs are more commonly found in home medicine cabinets than previously at hand to curious adolescents eager to try the “next high”. The increase in consumer marketing and access to the Internet has made many more individuals aware of these powerful drugs, and a great deal of information is available about them, how to obtain them, and how to use them.
However, a new source of opioid use will soon become apparent, as large numbers of formerly uninsured substance abusers enter the medical system as a result of the Patient Protection and Affordable Care Act (PPACA, aka “Obamacare”). The PPACA mandates that all insureds have a medical “home,” based upon a primary care provider (PCP). Many, if not most, PCPs have little experience with substance abusers and are understandably naïve about the effects of opioids when used in combination with many other medications, the guile and wiles used by many substance abusers, and the importance of screening tools, e.g., CAGE, SOAPP, ORT, DAST-10, to determine quickly a patient’s likelihood of substance use/misuse/abuse.
These clinicians will find the educational resources of the American Society of Addiction Medicine and their local addiction medicine organizations invaluable in avoiding the “4 Ds” of misprescribing (Wesson & Smith 1990):
• Dated: not current with prescribing practices or current drug use/misuse patterns
• Duped: deceived and/or manipulated into prescribing at variance with accepted medical standards
• Dishonest: subverts medical practice for personal financial gain
• Disabled: the clinician’s own impairment hinders exercise of optimal judgment
A critical element in the avoidance of over-prescribing is obtaining a family history of substance misuse/abuse. Brief screenings can help to identify individuals who should be prescribed opioids with caution. A sampling of SBIRT, or Structured Brief Intervention and Referral to Treatment, screening tools can be found at www.integration.samhsa.gov/clinical-practice/sbirt or through a Google search. SAMHSA also offers an “Opioid Overdose Prevention Toolkit” with information for prescribers, patients, families, first responders, and community members. State prescription drug monitoring programs, such as CURES in California, can alert physicians whether a patient is gaming the system.
Prescription guidelines from state medical boards and societies are also available. Additionally, the SCOPE of Pain program at Boston University offers several resources www.scopeofpain.com. In the future, genetic testing will more clearly identify those susceptible to substance misuse.
As increasing numbers of patients with substance misuse issues enter the medical system, primary care providers must have additional education, training and information to appropriately treat the unique needs of those in recovery and at risk for misusing opioids.
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