The Opioid Crisis . . . Is It Still a Crisis?
During the past year and a half, we’ve detailed the efforts of the federal government and many state governments to combat the opioid crisis. We devoted a blog series to the Department of Health and Human Services’ five-part strategy to curb the epidemic. We’ve discussed educational efforts for prescribers and revisions to prescribing guidelines which aim to minimize the use of opioids. We’ve also described the ways in which states have made naloxone available without a prescription despite the fact that naloxone has not been granted over-the-counter status by the FDA. With all of these efforts in mind, it’s only natural to wonder if all of this is working. And the answer is . . . yes and no.
The Centers for Disease Control (CDC) statistics demonstrate that the total number of opioid prescriptions dispensed in the U.S. decreased by nearly 25% from 2010 to 2017. The total number of opioid prescriptions dispensed in the U.S. in 2017 was just over 191 million, down from just over 251 million in 2010. Based on total population, these numbers translate into a rate of 81.2 and 58.7 opioid prescriptions per 100 persons in 2010 and 2017, respectively. Despite the overall decrease, there are still certain geographic regions which continue to be problematic. For example, in 2017, 16% of U.S. counties had enough opioid prescriptions dispensed for each person in the county to have had one. Perhaps even more disturbing is the fact that drug overdose deaths have not decreased. In fact, they have increased. In 2017, there were a total of 70,237 deaths attributable to drug overdose and of those, 47,600 (67.8%) were related to opioids. The age adjusted rate of overdose deaths related to opioids increased significantly by 9.6% from 2016 to 2017. In 2017, the states which had the highest rates of drug overdose were: West Virginia (57.8 per 100,000 persons), Ohio (46.3 per 100,000 persons), Pennsylvania (44.3 per 100,000 persons), Washington D.C. (44.0 per 100,000 persons) and Kentucky (37.2 per 100,000 persons). A total of 23 states had statistically significant increases in drug overdose death rates from 2016 to 2017. What these statistics suggest is that while we’ve made great strides in changing prescribing patterns, we have failed to reach those struggling with addiction. Collectively, prescribers are prescribing fewer opioids but the opioids are still finding their way to those with a history of opioid misuse, who are more likely to experience an overdose.
The CDC has highlighted several states which have demonstrated tremendous success in their efforts to reverse opioid statistics. Between 2010 and 2015, the state of Florida observed a decrease in the number of opioids prescribed in 80% of counties. These decreases are attributable to mandatory opioid reporting to the state’s prescription drug monitoring program (PDMP) and a pain clinic regulation which prohibited health care providers from dispensing opioid medications from their offices. The pain clinic regulation has also been hailed as the reason why, in 2012, Florida saw more than a 50% decrease in oxycodone overdose deaths. This was noteworthy because it was the first significant documented decline in drug overdose mortality in any state in the previous ten-year period.
In 2013, the state of New York began requiring prescribers to check the state’s PDMP before prescribing opioids. The result was a 75% decrease in patients seeing multiple prescribers for the same drugs in 2013.
In Oregon, the Oregon Health Authority (OHA) is responsible for reporting the rate of poisoning due to prescription opioid overdose. The OHA reported a 36% decrease in opioid overdose between 2006 and 2013. The OHA also reported a 58% decrease in methadone overdose between 2006 and 2013. Several earlier interventions are thought to be responsible for these decreases. One reason is the establishment of a PDMP in Oregon. Another reason is the Oregon Medicaid agency’s implementation of a prior authorization requirement for methadone doses greater than 100mg per day. A third reason is the efforts which were expended to give laypeople access to naloxone and teach them how to use it in cases of suspected overdose. A fourth reason is all of the physician and allied health training in the area of safe and effective pain treatment. You can read about these and other successful state efforts on the CDC website by clicking here.
war on opioids is still raging. Clearly, we have made significant advancements
in altering prescribing patterns for these drugs but we still have a long way
to go in changing opioid overdose death rates. It will take a tremendous amount
of thought leadership in the area of addiction medicine, combined with funding
commitments, support from health care providers and most importantly,
engagement from the population that is in the greatest need of intervention.