In part 1 of this blog I thought about the chain of decisions that has led to the current opioid epidemic in the USA and proposed interventions at each of the points 1 to 5 (see below), focusing on limiting supply through innovative approaches addressing drug manufacture, licensing and onward promotion and prescription by the medical profession. In this second part, I’ll cover points 6 to 10, issues related to individual consumers and reducing rates of dependence and overdose.
1. Drug companies make medications which get licensed by the FDA
2. Drug companies advertise drugs
3. Drug companies educate doctors
4. Doctors prescribe drugs and make money
5. Insurance companies make money
6. Patients/people take the drugs and some get high
7. Some patients/people get dependent and need more medication
8. Some people other the patients take the opioid medications
9. Doctors stop prescribing the medication so patients seek heroin
10. Patients die
6 & 7 Educate patients
It’s hard to imagine that any patient in the US is unaware of the addiction risks of prescription opioids but research done by GDS a few years ago suggested less than half of those receiving opioid analgesics had been warned of the abuse potential of their medications. Opioids are amazing pain killers but have little role or evidence base in the long-term management of pain. Opioids are nice drugs they offer both physical emotional pain relief but taken for periods of more than a month or two, tolerance develops and doses increase. The idea of bad patients and bad drugs is a myth. All opioid drugs can be misused and many people who use opioids meds for legitimate reasons may also occasionally use then to get high. The way to minimise the risks of things to progressing to harmful patterns of use is regular clinical review and good assessment.
The risk of developing dependence is less when using lower potency opioids, lower doses and for shorter periods. Effective pain relief can be obtained with lower doses when opioid analgesics are augmented by other medications or physical and psychological therapies. While not as easy and perhaps as pleasant as opioids these other approaches (anti-inflammatory drugs, cannabis in some cases, physiotherapy, weight loss, CBT, acupuncture and other alternative therapies) may be of real help. So, insurance companies need to reimburse these other treatment modalities and patients need education, understand these drugs are used most effectively on a short-term basis and need to know the risks. This could easily be done by giving all patients a letter at the start of treatment explaining the shared responsibility of patients and doctor outlining how these medications work, the risk and why treatment response and medication dose will be monitored closely and does kept to a minimum to avoid the risk of harms.
8 Medication storage
Many people’s first experience of prescription opioids is when they access another person medication, Mum’s, uncles’ friends. Every person in receipt of prescribed opioid analgesics need lock their meds out of reach of other members of their family this limits the chances of accidental introduction to others.
9 Honest conversations, transparency and informed patients
Doctors always need to explain the decision they make and why certain treatment options are favoured over an another. When physicians think their prescribing is out of control and that either their patients are taking advantage or coming to harm or they worried about being investigated the knee jerk response to suddenly stop prescribing is not right or fair. They need to take responsibility and work with their patients to craft a clinical cared plan where safety is prioritised. Do otherwise leaves the most vulnerable people in need of an alternative supply. Today in the USA that supply is heroin, increasingly contaminated by potent synthetic opioids like fentanyl.
10 people die
Reducing access to potent opioid analgesics on demand is only part of the solution. For those whose lives are diminished and run by dependence on opioids now we need naloxone on every street corner available free from vending machines and outreach facilities with peer training on how to put people in the recovery position something every high school kid should know. There needs to be open access to
non-stigmatising harm reduction based treatment centres and upskilling of family physicians so make it easy to get help. Consideration needs to be given to supervised injecting centres in high risk areas.
In many parts of London, you can get on a script for methadone or buprenorphine within 48 hours. Not to have access to swift and effective treatment is costing tens of thousands of lives each year and costing the US government untold billions through lost productivity and use of emergency services and pointless incarcerations for personal possession. Even if you don’t care for the people whose lives are ruined by drugs on a purely economic basis treatment is a good idea. It saves lives and money – offering a return of at least $3 on every $1 invested in treatment – far better than the trillions wasted on the war on drugs and totally more evidenced than any wall or campaign to encourage kids to just say ‘no’. America needs to build bridges to treatment not walls to increasingly isolate itself from the modern world where drug treatment and policy is being riven by evidence not ideology and naïve political rhetoric
Addressing the other drivers for addiction such as poverty, abuse, stigma, emotional and social deprivation, trans-generational disadvantage and inequality might help as well (it would help loads OK) but let’s start with the easy things first eh? If you want to add your voice to the world’s largest drug survey, and help us tell the truth about drugs so we can help people having honest conversations please take time out to participate the world’s biggest drug survey at www.globaldrugsurvey.com/GDS2018