Opioids claim more than 40,000 lives each year. More than seventy-five percent of these deaths result from an overdose on fentanyl and other synthetic opioids (Mann, 2018).
Unfortunately, the danger of opioids was unknown to the general public and health community in the late 1990s and early 2000s. Opioids are highly addictive and create brain abnormalities after long-term use. Increased prescription of opioid medications such as Oxycontin and Morphine lead to chemical dependence, which can result in the abuse of prescription and synthetic opioids. Furthermore, opioid withdrawal symptoms force patients to become dependent on the medication (Kosten et, al. 2002).
Using opioids to treat pain is a relatively new medical intervention. In 1986, the World Health Organization led a Cancer Pain Monograph in which they addressed the under-treatment of pain. As a result, multiple articles were published which questioned the lack of pain medicine. In the 1990s, the health care industry was pushed to treat pain more effectively. Fueled by the discovery of long-acting oxycontin, doctors prescribed opioids to treat long-term pain. At first, Oxycontin was misbranded as a safe medication. Purdue Pharma, the manufacturer of Oxycontin, claimed: “the rate of addiction among patients who are treated by doctors is much less than one percent”. (Mann, 2018). In retrospect, the use of opioids was not backed by any scientific studies.
In the early 2000s, the Joint Commission pressured doctors to provide adequate pain control to their patients. As a result, we began to see an increased number of opioid prescriptions. In fact, Oxycontin prescriptions and consumption rose dramatically from 1997 to 2002. Despite this, opioids did not raise concerns until after 2002. In 2003, reports found that the number of opioid oversedation incidences had doubled in association with deaths related to respiratory depression. These events marked the beginning of the current opioid epidemic. Since 2003, prescription opioid sales and related deaths have quadrupled, despite American’s reporting no average increase in pain (Davis, 2019). Finally, in 2017, the opioid epidemic was declared a public health emergency by the US Government. (National Institute on Drug Abuse, 2019)
The opioid epidemic is one of the most challenging public health crises of our time. It has taken an enormous toll on our society. This epidemic has broken families and ravaged communities across the United States. Infants born with neonatal abstinence syndrome related to maternal opioid use suffer and require specialized treatment. Furthermore, many parents with opioid use disorder have their children removed from their homes and placed with social services and custodial care. (Florence, 2013). Moreover, opioid addiction results in lost tax revenue from reduced earnings.
On average, 25% of patients who are prescribed opioids abuse them. Moreover, 80% of people that use heroin first abused prescription drugs (National Institute of Drug Abuse, 2019). These statistics display the danger of prescription opioids. On the other hand, they provide a glimpse of the danger of restricting them altogether. Instead of prohibiting opioid prescriptions, patients need to be provided with recovery and treatment services. If not, prescription opioid-related related deaths may decrease, but heroin-related deaths will increase.
I propose a policy to reduce opioid abuse by implementing a series of steps to increase access to evidence-based care and opioid use disorder treatment.
Reducing initial opioid prescriptions is a crucial step in preventing the expansion of the current opioid epidemic. These prescription medications are dangerous and have led to opioid abuse disorders. Doctors must be restricted from prescribing opiates to patients experiencing acute onsets of pain. In fact, primary care providers are responsible for nearly fifty percent of all opioid prescriptions. Furthermore, primary care physicians prescribe opiates at higher rates compared to other medical specialties. (Serafini, 2018). At primary care clinics, pain will not be disregarded. Instead, multiple treatments will be attempted before prescribing opioids.
To combat the current opioid epidemic, opioid abuse must be decreased by increasing access to evidence-based care. For patients on low doses, primary care physicians must develop care plans to transition the patient to chiropractic care, physical therapy, and occupational therapy. Extensive medical research has provided evidence for the effectiveness of these therapies. Patient with chronic, painful conditions such as cancer can be referred to a pain management specialist for opioid treatment.
Unfortunately, patients with a long history of opioid use experience withdrawal symptoms and develop opioid dependence. Withdrawal symptoms include vomiting, body aches, restlessness, and increased heart rate. Although not life-threatening, withdrawal symptoms can become severe and impact quality of life. Many patients seeking symptom relief choose to continue using opioids. This leads to dependence, the physical and psychological need for opioids.
Without access to prescription opioids, dependent patients turn to family or friends for medication. Unfortunately, some of these individuals turn to the streets to buy heroin. Heroin works like other opioids to produce a dopamine rush. It is cheap and accessible. Heroin creates a public health concern because intravenous use can spread HIV and hepatitis C among users. Lately, there have been many news reports about overdoses on heroin, especially when laced with fentanyl. Fentanyl is 100 times more potent than morphine, which accounts for its high overdose and death rate.
We do not want patients with opioids use disorders to turn to street drugs. Unfortunately, only 20% of patients with opioid abuse disorders are getting treatment. Most physicians do not know how to treat these patients, so they turn them away (Mann, 2018). Furthermore, these patients require long-term treatment and have low reimbursement rates. Moreover, there is a shortage of physicians specializing in substance abuse. Substance abuse disorder specialists are needed to work alongside primary care physicians to provide optimal health care delivery to this population of patients.
To address the growing concern of opioid abuse disorders, we must provide medication-assisted treatment to patients. Medication-assisted therapy uses opioids with lower rates of addiction, such as buprenorphine and methadone, to treat patients over time. (Serafini, 2018). From my experience working as a medical scribe at a substance abuse clinic, medication-assisted therapy is effective and reduces the likelihood of opioid abuse. Patients must be monitored by a monthly doctor’s visit. Furthermore, medication dosages are to be decreased gradually over time. Opioid-agonist therapy with suboxone and buprenorphine are regarded as highly effective in the medical community. Despite this, these medications are inaccessible to 80% of patients who need them. Lack of funding has resulted in the inaccessibility of these medications. Last year, only 20% of patients with substance abuse disorder were receiving medication-assisted therapy. Moreover, less than 5% of physicians are certified to dispense agonist therapy. (Davis, 2019). There needs to be an expansion of medication-assisted treatments as well as an increase in certified providers to prescribe these medications.
To provide optimal care delivery, access to rehabilitative services must be expanded to all Americans with opioid use disorders. Rehabilitative services provide patients with a nonjudgmental support system in which they receive assistance in overcoming their opioid dependence. These facilities manage patient withdrawal symptoms with medical treatments in a supervised environment. Also, patients can be referred to long-term residential centers for social and psychological treatment. Physicians need to work with each individual patient to develop and manage a care plan. Physicians must partner with rehabilitative agencies to refer patients in need of treatment.
If implemented, the aforementioned proposal has the ability to decrease the prevalence of the opioid epidemic. Reducing initial opioid prescriptions will prevent new cases of opioid dependence. Instead, patients with pain will be referred to specialty doctors for pain management. Also, increasing access to opioid use disorder treatment will prevent the use of synthetic opioids and reduce opioid-related deaths. It has been projected that the use of services such as medication-assisted and psychosocial treatment can increase life years. Moreover, research shows that increasing access to therapies such as naloxone and methadone has the potential to cut overdose deaths by 6,000. This is estimated over a 10-year period and compared to what would occur if current trends continue (Brandeau, 2018)
Unfortunately, critics may argue that expanding these services costs money. Many insurance companies will not want to cover expensive rehabilitative treatments. Medicaid reports that states do not cover enough alternatives, which prevents people from accessing services that will allow them to integrate into society without their substance abuse disorder (Serafini, 2018). Furthermore, there are not enough doctors certified to prescribe medication-assisted therapy to meet the needs of the population. Moreover, restrictions may unintentionally harm patients with a legitimate need for opioid medications. There is also a chance that further restrictions will lead insurance companies to deny drugs. As a result, patients who need opioids will have to endure long wait times for paperwork and prior authorization approvals. Lastly, these restrictions may result in pharmacies stocking fewer opioids, leaving patients to wait or travel long distances to get their medications.
In my proposal to battling the opioid epidemic, the stakeholders include physicians, insurance companies, and pharmaceutical companies.
Physicians are at the forefront of the opioid epidemic. Primary care, pain management, and emergency care physicians will be addressed at national briefings, in which resources and information about the policy will be provided. Furthermore, physicians will be able to provide feedback on their ideas. Feedback will be considered before the final implementation of the policy. Physicians will be encouraged to present key findings throughout all phases of implementation. Adjustments will be made throughout the different phases, if necessary. Physicians with their own private practices will receive in-depth training and resources to implement the National Opioid Tracking system. All physicians will be offered technical training on the National Opioid Tracking system through an online session.
Collaborating with insurance companies will include national meetings to discuss the savings and benefits of the policy. Providing alternative therapies and treatments for opioid use disorder will increase demand for these health services, which benefit insurance companies. Insurance companies will be encouraged to control the spread of opioids and provide assistance to Americans looking to overcome their opioid use disorder.
Due to restrictions on opioids, pharmaceutical companies are likely to lobby against the implementation of the policy. Pharmaceutical companies will be advised that most patients with opioid use disorder will transition from long-acting opioids such as Oxycontin to weaker opiates such as buprenorphine. Furthermore, my team is prepared to undergo lobbying efforts against the pharmaceutical industry. The lobbying effort will include information about the pharmaceutical push for pain medications in the 1990s, which led to the current opioid epidemic.
Tackling the opioid epidemic will take time. The plan to implement the aforenoted policy will occur in 4 phases. Facilities will have one year to implement each phase. At the end of year 4, all phases must be implemented. Failure to implement the policy will result in a fine of up to $100,000 for each healthcare facility.
In the first year, laws will be implemented to place restrictions on opioids in all 50 states. Currently, 32 states do not have any restrictions on opioid prescriptions. Restrictions will include limiting the length of opioid treatment to less than 7 days for patients experiencing pain.
Furthermore, during this phase, doctors will be recommended to prescribe non-steroidal inflammatory medications (NSAIDs) such as ibuprofen before resorting to opioids. If the patient reports no pain relief with these drugs, stronger NSAIDs such as Meloxicam should be used. In the instance that these stronger NSAIDs do not relieve pain, patients will receive a 3 to 7-day supply of opioid medications along with a referral to a physical therapy or pain management facility.
There will be fewer restrictions on opioid prescriptions in a pain management setting. Each patient will be partnered with a care coordinator who will work with the physician to perform routine urine drug screens and monitor for signs of abuse. Furthermore, no refills on the opioid will be allowed. Instead, patient’s on opioids for long-term pain management will need to be seen by the pain management specialist on a monthly basis.
During the second year, all states will be mandated to incorporate the National Opioid Tracking system. This system will be used for the electronic prescription of controlled substances. Also, to record each patient’s opioid medication history. Electronic prescriptions prevent the alteration of medical documents. Furthermore, uniting all states through a national database will decrease the incidences of opioid abusers crossing state lines to seek medications from other physicians. Information in this database will be used to track patients, gather research data on opioid prescribing patterns, and monitor opioid use.
In the third year of implementation, primary care physicians will be encouraged to undergo training for authorization to prescribe medication-assisted therapies. These doctors will be authorized to treat opioid use disorder with buprenorphine and methadone. Furthermore, programs will be developed to train doctors in becoming substance abuse specialists. Doctors choosing this specialty will be offered a competitive salary.
Doctors will receive higher compensation for treating substance abuse patients due to the length and complexity of the cases. Also, doctors authorized to dispense medications such as buprenorphine will have a cap of 100 patients on agonist therapy.
During the fourth and final phase of the policy, physicians will partner with facilities that offer detoxification and rehabilitative programs. Doctors will be ready to provide education to patients about these services. Furthermore, Doctors will work with the patient and rehabilitation facility to develop a care plan and seamlessly transition care over to the new facility. Physicians will be responsible for developing a system to follow up with each patient they refer. Support will be provided to assist in the implementation of said system. Also, healthcare facilities must be proactive in reaching out to each patient for follow-up appointments.
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