Editor’s Note: Reporter Newspapers has launched the special four-part series “Coping with a Crisis: Opioid addiction in the suburbs,” about local responses to an epidemic that is killing people nationwide and right here in our communities. Opioids are a class of addictive, often easily lethal drugs that include opium and morphine as well as substances with similar effects. Many opioids have legitimate medical uses for painkilling, but also can produce physical addiction and a sense of euphoria that attracts recreational drug users. National controversy has raged over opioids available as prescription pills, such as oxycodone, while illegal varieties such as heroin and fentanyl now kill the most people through overdoses. Together, these opioids present complex problems to solve in both supply and demand. Hospital emergency rooms are a front line where opioids can be administered and where overdoses can be treated. The Reporter asked one local ER doctor to discuss the scope of the opioid crisis and what it brings through his doors every day.
An opioid epidemic is sweeping this country. The National Institutes of Health’s (NIH) Institute on Drug Abuse currently estimates that 115 Americans die daily from opioid overdose. The NIH reports that 25 percent of “chronic pain patients” misuse opioids, and 10 percent of those patients develop an “opioid use disorder.” Five percent of those patients will eventually move on to heroin. Eighty percent of heroin users misused prescription opioids first.
This is primarily an American problem, with a staggering 80 percent of the global supply of opioids being consumed in the United States. The Centers for Disease Control and Prevention (CDC) estimated in 2013 that the economic cost of the opioid epidemic in the U.S. approximated $78 billion dollars annually.
The epidemic has taken a while to become this prevalent, and many believe the problem dates back to the 1990s. That’s when the American Pain Society began to put forth the idea that pain was being undertreated. This eventually led to the concept of pain being “the fifth vital sign.” Vital signs traditionally are objective pieces of data used in medicine. Pain, however, is a completely subjective piece of data.
The regulatory agencies of healthcare, The Joint Commission, a healthcare accreditation organization, and the Centers for Medicare and Medicaid Services (CMS) latched onto the concept of the “under-treatment” of pain. In 2001, the Joint Commission put standards in place recommending that all patients in a healthcare setting must have their pain assessed, as well as a documented response to the pain assessment. These eventually became requirements with ramifications for financial reimbursements to healthcare entities. This led to the near universal adoption of pain as the fifth vital sign in U.S. hospitals. So, when you come to the Emergency Department with bronchitis or to have an insect removed from your ear canal, you will be asked, “What is your Pain Score?”
This did not go unnoticed by the pharmaceutical companies. OxyContin, a long-acting narcotic, was first marketed in 1996. Big Pharma has benefitted significantly from opioids, over-exaggerating the benefits while downplaying the addiction risks. This has currently prompted New York City to file lawsuits against the pharmaceutical companies for the manufacturing and distribution of the opioids.
However, today the majority of opioids in this country are illegally obtained and distributed. The amount of narcotics being received from Emergency Department prescriptions are in the minority.
Opioid overdoses and fatalities have, unfortunately, become commonplace. They are seen in the Emergency Department on a daily basis. The Emergency Department providers get lied to by patients every single day, as patients attempt to receive narcotics. Drug dealers are known to pay patients to come to the Emergency Departments with fake illnesses to get prescriptions. The most common methods employed are faking kidney stones, back pain or abdominal pain. These patients know to list their allergies to aspirin, NSAIDs and Tylenol, so as to ensure that narcotics are all that can be used to treat their “pain.”
There are patients who actually inflict injuries upon themselves to receive prescriptions. Patients will go from Emory Saint Joseph’s Emergency Department directly across the street to Northside Hospital’s Emergency Department to try to receive another prescription, and vice versa. Patients are known to go from provider to provider, place to place, “doctor-shopping.” This has ramifications on the suffering patients who actually have pain.
The Joint Commission, CMS, the CDC, NIH, and federal and state legislatures, along with healthcare providers, have all gotten together to try to remedy this situation. Emergency Department providers have been clamoring for years to get a centralized prescription drug monitoring system in place. Georgia and other states recently have provided this capability. The first patient I ever looked up in the Georgia prescription database had 28 prescriptions for narcotics from 21 different providers and 15 different pharmacies in a 12-month period!
The effort may be starting to make a difference. Prescriptions for opiates have actually declined since 2013, although overdoses and fatalities have not. Most Emergency Departments now rarely prescribe “long-acting” narcotics. Most only prescribe narcotics for the shortest time period possible. Other non-narcotic means of pain relief are being recommended.
These steps should help eventually as the volume of prescription opiates decline. However, pharmaceutical companies will need to be regulated and held accountable, and the illegal opioid market will need to be curtailed, if long-lasting change will ever have the hope of taking place.
Dr. Alan A. Farabaugh is an emergency medicine physician at Emory Saint Joseph’s Hospital in Sandy Springs.