FEATURE
toring “the fifth vital sign” encouraged physicians to make their
patients free of pain. In those days the prescribing of hydrocodone
with acetaminophen was the norm. For a number of companies in
the manufacturing sector, the use of Vicodin was the highest pre-
scribed drug by volume of pills. Vicodin was first introduced into
the market by Abbott Labs in 1984. Eleven years later, OxyContin
was marketed by Purdue Lab as its proprietary version of oxycodone.
The combination of prescribing narcotic meds to keep people free
of pain and aggressive marketing of these drugs by pharmaceutical
companies created a high demand.
But not all patients prescribed narcotics become addicted. Esti-
mates from various sources place between one percent and 25 per-
cent of opioid addicted people note that they started their addiction
with physician prescriptions for acute pain. The use of marijuana
as a “gateway” to opioid use has been studied. Marijuana has been
shown to enhance the addiction to caffeine and to nicotine. There
is the assumption that it would also enhance the tendency to use
“hard drugs.” The National Institutes of Health has been reviewing
the evidence but has yet been unable to indicate whether marijuana
use leads to a tendency for use of opioids by itself.
Of the 97 million people in the U.S. who took a prescription nar-
cotic, 12 million did so without a legitimate prescription. Diversion
of prescribed opioids is a major issue. This is accentuated by the
liberal prescribing of physicians and dentists. Highmark Blue Cross
found that following a dental visit where pain killers were prescribed,
that the average prescription was for a 28-day supply. Most dental
patients do not need narcotics after the first few days. This leads to
a large volume of unused pills. In a study of 1.2 million Medicare
beneficiaries, who received at least two narcotic prescriptions in
2011, that 34 percent received those from two physicians, 14 percent
from three providers, and 12 percent from four or more physicians.
Given the difficulty in sharing information on prescribing in many
states, this is not surprising. Kentucky was among the early states to
adopt the communication platform, KASPER, which allows doctors
to know the prescribing of other colleagues.
There is, of course, the distinction that needs to be made between
tolerance of a prescribed opioid that requires a higher dose to achieve
the same level of pain relief, and physical dependence that would
require a drug taper to avoid withdrawal symptoms. Addiction is
an independent issue and not as predictable as either tolerance or
physical dependence. Only a fraction of people prescribed opioids
do become addicted, but that number is quite significant in a so-
cietal context.
As people become dependent or addicted to prescribed narcotics,
the cost and access barriers may become significant. Heroin and
other street drugs, including non-prescribed fentanyl, become less
expensive alternatives.
So what are the strategies to curb this epidemic? The current na-
tional strategies are focused on reducing access to higher-than-need-
ed volumes of prescribed narcotics, initiation of more drug treatment
programs, and public access to life-saving naloxone:
1. REDUCING ACCESS TO HIGHER-THAN-NEEDED
VOLUMES OF PRESCRIBED NARCOTICS.
This strategy is to reduce the number of people becoming
addicted to prescription drugs and to reduce diversion. It will
not solve the issue of those who are currently addicted. Indeed
there is concern that those addicted to prescribed narcotics
may turn to street drugs if the source of their addiction is
restricted. This complex set of physician-managed strategic
goals demands a multi-stage approach by doctors who write
narcotic prescriptions, including:
» » Assessment of need: as a profession we need to recognize
that people in acute pain should be treated but be limited
in the supple to “just enough” rather than the insurance
covered 30-day supply.
» » Verification that there is no other active prescription:
drug monitoring programs such as KASPER can verify
the number of active prescriptions and the pattern of use.
» » Assessment of addiction potential: use office-based screen-
ing tools to assess potential addiction such as the Opioid
Risk Tool or the Screener and Opioid Assessment for
Patients with Pain.
» » Verification of use: the use of urine drug screening for
patients at risk can indicate if the patient is using only the
drug prescribed. If used, such tests need to be randomly
performed and part of a contract.
» » Develop a doctor-patient contract for management of
prescribed narcotic. Such a contract becomes the written
basis for managing expectations.
2. INITIATION OF DRUG TREATMENT PROGRAMS
For some individuals, it is appropriate to become “clean” and
discontinue use. As with other addictions, treatment programs
focused on initial medical treatment for detoxification and
physical withdrawal that is coordinated with management of
the addiction. This can range from Narcotics Anonymous based
programs (in Louisville: www.nalouisville.net) to long-range
treatment programs. Psychology Today has a link to treatmen t
facilities in Louisville (https://treatment.psychologytoday.com/
rms/prof_results.php?city=Louisville&state=KY&spec=232)
The City of Louisville Office of Addiction Services has a listing
of its services on its web page (https://louisvilleky.gov/govern-
ment/health-wellness/office-addiction-services)
For other patients, maintenance rather than cure is the pre-
ferred treatment. The two principal maintenance programs
involve either methadone or suboxone. Both now require a
specific license. Louisville has two methadone clinics, both of
which use the liquid form and require the addict to come on
a daily basis. Methadone can prevent withdrawal symptoms
JANUARY 2018
11