Webinar encourages health systems to track prescriptions
During a CHA-hosted webinar, a drug policy expert from Brandeis University pointed to the overprescribing of opioids as a key culprit in the nation's current drug addiction epidemic.
Kolodny
Dr. Andrew Kolodny said that the soaring rates of opioid addiction and fatal overdose track back to 1996 when Purdue Pharma introduced OxyContin, an extended-release opioid in pill form. The company aggressively promoted its drug to physicians for the treatment of chronic pain, and its overprescription is a root cause of the epidemic of opioid addiction in the U.S., he said.
Despite what is now known about the addictive properties of opioid-derived painkillers, Kolodny said they continue to be overprescribed.
"We need to stop stocking homes with highly addictive drugs — we need more cautious prescribing," Kolodny said during the Nov. 8 CHA webinar: "How Can Hospitals Support Community Efforts to Fight the Opioid Addiction Epidemic?" Kolodny co-directs opioid policy research for Brandeis and is the executive director of Physicians for Responsible Opioid Prescribing.
Fast actor
Kolodny explained during the webinar that prescription opioids including oxycodone, the active ingredient in OxyContin, and hydrocodone are made from opium, with the opium molecules manipulated to reach the brain faster. He said these drugs' effect on the brain is virtually indistinguishable from that of heroin, another opioid.
Kolodny said opioid addiction, overdose and deaths caused by overdose have risen precipitously — particularly in recent years — throughout the U.S. He pointed to several factors driving the trend line including the lingering effects of Purdue Pharma and other drug companies having marketed opioid-based painkillers as nonaddictive even with long-term use.
Kolodny said medical use of opioids can normalize narcotic use for people with no prior history of drug abuse and continued use can produce dependency on the drug's narcotic effects.
In 2010, Addiction, the journal of the Society for the Study of Addiction, published a study identifying risk factors for opioid dependence. Researchers followed 700 patients who took prescription opioids for a year or longer. More than a quarter of that group developed drug dependency. The researchers said that risk factors for dependency include being younger, in poor health, or severe pain and their research supported previous findings that mental health markers including depression, anxiety and past substance abuse can increase the risk of developing opioid dependence.
A study in a March 2017 issue of Morbidity and Mortality Weekly Report, a publication of the Centers for Disease Control and Prevention, looked at the likelihood that a patient's opioid use would become long-term. It is based on the prescription durations of a random sample of approximately 1.3 million cancer-free adults. It found the risk for chronic opioid use increased with each additional day prescribed, starting with the third day.
Because of the known risk of dependence, it can be difficult for people to continue to receive the prescriptions they desire from one provider. Some patients who have developed a dependency on the drug seek out pill mills where unethical physicians routinely prescribe opioids for cash. People sell and buy pills on the black market too. Many people who became dependent on opioid prescription drugs have turned to heroin, which is generally cheaper than opioid-based pills.
In recent years, the synthetic opioid fentanyl has spread throughout the illegal drug supply in the U.S. Kolodny said fentanyl is more potent than heroin and less expensive because its production does not require the use of opium. Kolodny said the use of fentanyl in heroin has made the illicit drug supply more dangerous because a minute quantity of fentanyl can be deadly.
He said that as clinicians began prescribing opioids for long-term pain relief, increasing numbers of people — particularly young and middle-aged white people — have become dependent. Some researchers say the difference between dependence and addiction is defined by supply. Accordingly, when a drug dependent person becomes drug seeking, that person would be defined as being addicted.
Kolodny said he suspects that clinicians have been more apt to prescribe opioids to white people than to black people because of a misperception, or a subconscious bias, that there is a race-based propensity toward addiction and that whites are at lower risk.
In late December, the CDC released a breakdown of 2016 drug deaths by race and geography that showed a sharp increase in opioid deaths among blacks whose addiction had not begun with a legal opioid prescription. Kolodny told The New York Times that it appeared the introduction of fentanyl into the heroin supply was driving a spike in drug-related deaths among older black men who had become addicted to heroin as young men.
Marketing plan
Kolodny told the CHA webinar audience that before OxyContin came on the market, opioid pain relief generally was used to treat short-term acute pain and terminal stage cancer pain. Clinicians were reticent to prescribe opioids for chronic, non-cancer pain.
Citing reporting by the Government Accountability Office, he said that to build sales of OxyContin, Purdue Pharma funded a sweeping, high-dollar marketing campaign to convince physicians that its drug was safe and effective for treating chronic pain, that opioid addiction is rare in pain patients, and that pain patients can discontinue the use of opioids safely and readily. "All of these were untrue," Kolodny said.
He said that Purdue Pharma hosted continuing medical education programs, organized patient activist groups and secured the support of professional societies and state medical boards — all with the goal of promoting the widespread prescribing of its product.
The drug company frequently cited the statistic that the risk of addiction is much less than 1 percent for patients taking opioids long-term, Kolodny said. This statistic originated in a one-paragraph letter to the editor in the New England Journal of Medicine in 1980 from a doctor who was describing addiction risk in hospitalized patients who received opioids for a short duration. The findings of his study did not apply to long-term use of narcotic painkillers.
Containing the fallout
Kolodny said that it has become commonplace to prescribe highly addictive drugs over a long term, in both medical and dental practices. He said evidence has shown that opioids are not effective for controlling pain over the long term, particularly given the risk of dependence and the fact that patients build tolerance for the drug and higher doses become necessary to achieve the same relief.
Kolodny said that to stop the epidemic, the U.S. must prevent new cases of opioid addiction, in large part by stopping the overprescribing of opioids, making treatment widely available to people who are addicted, and reducing the supply of opioids from pill mills and on the black market.
Kolodny noted that studies have shown that buprenorphine is effective in treating opioid dependence. There is a risk of relapse in patients who stop taking the drug, a semisynthetic narcotic analgesic. Kolodny said opioid detox and abstinence programs are less successful than the use of buprenorphine over the long term.
Kolodny told the webinar audience that Catholic health systems can be instrumental in the fight against opioid addiction by participating in local task forces addressing the crisis from a prevention, supply control and treatment promotion perspective. He encouraged health systems to track opioid prescribing and use the reduction of unnecessary prescribing as a performance improve–ment measure.
Copyright © 2018 by the Catholic Health Association
of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3490.