Opioid Abuse a Public Health, Not Law Enforcement, Issue

Pam Harrison

October 19, 2015

Adults in the United States view the problem of prescription opioid use and abuse mainly as a public health problem rather than a law enforcement issue and are fully supportive of a wide range of policies aimed at controlling the epidemic, new research shows.

"Right now we are in a situation where there are a whole host of different policies that have been proposed to tackle this epidemic, but other than some action on prescription drug monitoring programs, not a lot has been passed in terms of major polices regarding prescription opioid use," Colleen Barry, PhD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, told Medscape Medical News.

"But because the opinion of the public is relevant in decisions related to whether certain laws get enacted or not, we wanted to take the pulse of the public and find out if it is something on their radar screen," she added.

"And our study suggests that the public is viewing this issue as a broader public health issue as opposed to a law enforcement issue, and many of them see it as being a very serious or an extremely serious problem."

The survey results were published online October 7 in Addiction.

"Serious" Health Issue

Investigators fielded a web-based public opinion survey from January 31 to February 28, 2014, among a national sample of 1111 US adults to examine views about the abuse of opioids prescribed to relieve pain.

Respondents were asked about their personal experience with opioid pain pills, including whether they had ever had a problem with pain that was serious enough to lead them to seek medical treatment.

Respondents were also asked to rate the seriousness of 12 different health issues, including opioid pain pill abuse.

"Just over half the sample reported ever having had pain serious enough to go to the doctor for treatment, and of these, nearly 80% were offered opioid pain relievers," Dr Barry and colleagues note.

However, 45% of respondents reported that their physician also offered them a nonmedication pain management alternative at the time they were offered an opioid.

Only half of the respondents indicated that their physician had informed them about the risk for addiction when offering them an opioid medication.

Fewer than 10% of respondents reported taking opioid pain medications for "the feeling it gave, not to treat pain" or for "longer than originally prescribed," both potentially problematic pill-taking behaviors.

Fewer than 3% of respondents admitted that they had or have had a problem with opioid pill abuse, although about one third said they knew a family member or a close friend who did have a problem with abuse.

"Clearly, Americans have experience using these medications," Dr Barry said.

"One quarter reported using them within the last year, and 70% reported using them at some point in their lifetime."

Dr Barry also thought that a "pretty sizeable share" of respondents acknowledged some use of opioid pain medications that could be considered potentially problematic — in particular, the 17% of the sample who admitted that they had used prescription opioids that had not been prescribed to them.

More than half of the sample (58%) ranked the problem as either "very serious" or an "extremely serious" health issue, on par with alcohol abuse, smoking, and gun violence.

Respondents were also asked what they thought might be causing the opioid pain medication epidemic.

Doctors to Blame?

More than 80% felt that people who had become addicted were themselves to blame for their addition, but 78% also pointed a finger at doctors, offering that doctors made it too easy for patients to obtain multiple prescriptions from different physicians and that prescriptions were being meted out without thoroughly examining the patient.

"The most strongly endorsed policies to curb the epidemic included the requirement for pharmacies to verify patient identification before filling a prescription and requiring medical schools and residency programs to provide training in the detection and treatment of addiction to opioid pain medication," the investigators write.

The public also felt physicians needed training in the treatment of chronic pain to curb the potential for abuse.

The only two policies supported by less than a majority of Americans were to increase government spending to improve treatment of substance abuse and to provide naloxone (multiple brands) to friends and family members of those using opioid pain medication to counter the effects of overdose.

"We think this is the perfect time to work on passing policies that can truly impact the crisis of prescription pain reliever abuse," study coauthor Emma McGinty, PHD, assistant professor of health policy and management at the Bloomberg School, said in a statement.

"The issue has not yet been highly politicized like some public health issues, such as the Affordable Care Act, gun violence, or needle exchanges, so we may have an opportunity to stem this epidemic."

Man-made Epidemic

Asked by Medscape Medical News to comment on the study, Gary Franklin, MD, MPH, vice president of Physicians for Responsible Opioid Prescribing, confirmed that nobody thinks the prescription painkiller epidemic is a law enforcement issue.

"It's really the worst public health epidemic that has occurred in our history, and it's man-made," he said, "made by certain pain leaders and drug companies."

On the other hand, Dr Franklin doubted whether the average person on the street really knows much about the problem of prescription pain abuse and the magnitude of the epidemic.

"If you asked somebody on the street how many people have died from the prescription pain problem, they wouldn't even be able to guess that in the US, over 175,000 people have died from prescription opioids alone since about 1999," Dr Franklin said.

He also had problems with the wording used in the survey, feeling that through the use of terms such as "abuse" and "misuse," "people feel that it's all the patient's own fault that he or she has become dependent on opioids."

On the other hand, survey respondents also blamed physicians for overprescribing or misprescribing pain medication and not talking enough about addiction — again, responses that might have been elicited by the wording used in the survey.

Dr Franklin, who is also an adjunct research professor of health services at the University of Washington, in Seattle, noted that there are useful ways to begin to curtail the prescription opioid epidemic, starting with appropriate prescribing practices.

He and his colleagues have now completed three guidelines on appropriate prescription opioid use, taking into consideration the dose of the drug. These are the first guidelines to focus on dose as a problem in opioid overdose and death.

The Centers for Disease Control and Prevention, in Atlanta, Georgia, will be presenting new guidelines on the use of prescription opioids in January 2016, which Dr Franklin feels is a "very big deal."

In the meantime, perhaps the best advice comes from three editorialists, under lead author Lewis Nelson, MD, New York University School of Medicine, New York City, writing in JAMA.

"Dependence, addiction and dose escalation resulting from tolerance make discontinuing opioids difficult," the editorialists write.

"Although multifaceted approaches are needed to successfully address the opioid epidemic, an important step is to start at the beginning and keep opioid-naive patients opioid naive."

Funding for the study was obtained through a research grant from AIG, Inc. Neither Dr Barry nor Dr Franklin have disclosed any relevant financial relationships.

Addiction. Published online October 7, 2015. Abstract

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