Drug overdoses killed more than 100,000 Americans in the first year of the Covid-19 pandemic, as pressures built and users sometimes had to get their fix from unfamiliar sources. Experts discuss how the pandemic cost lives beyond Covid, and how surgical painkiller drug substitutions are beginning to keep some people from going down the opioid path.
Before the worldwide coronavirus pandemic, the opioid epidemic was a crisis spreading rapidly across the nation. According to the CDC, from 1999 to 2019 nearly 500,000 people died as a result of a drug overdose involving an opioid.
Then, starting in 2010, prescription opioids became more difficult to obtain. The already-deadly opioid epidemic grew even more bleak as users opted for the cheaper and more readily-available alternative: heroin.
In 2013, the epidemic grew even deadlier still, as synthetic opioids, like fentanyl, flooded the illicit drug market. From 2018 to 2019, nearly 73% of opioid-related deaths involved synthetic opioids.
Add in the coronavirus pandemic on top of all of that, and the United States is facing an even more formidable crisis, further exacerbated by the uncertainty, lack of access to care, and social isolation.
Dr. Thomas Stopka, Associate Professor of Public Health and Community Medicine at Tufts University, explains:
The Covid-19 pandemic certainly didn’t help and maybe greatly exacerbated the current situation with mental illness. That includes your substance use disorder and opioid use disorder. Now is the time to invest adequate support, to try to bring about change.
Guest Information:
- Dr. Thomas Stopka, Associate Professor of Public Health and Community Medicine, Tufts University
- Dr. Luke Elms, general surgeon, Orlando Health Dr. P. Phillips Hospital
Links for more info:
- Thomas Stopka, Ph.D., MHS – Tufts University profile
- Survey: Most willing to forgo opioids after surgery if pain can be effectively managed without them – medicalxpress.com
21-51 Easing the Opioid Epidemic
Reed Pence: This is Radio Health Journal. I'm Reed Pence. This week, drug overdoses claim more than a hundred thousand lives in a year.
Dr. Thomas Stopka: We just have to pull out all the options, think creatively… And it's sad, it's scary and frustrating that we're continuing to go in the wrong direction.
Reed Pence: Making opioids emergency painkillers when Radio Health Journal returns...
Just before Thanksgiving, the federal government confirmed what a lot of health experts already suspected. During the first year of the Covid pandemic, drug overdoses claimed the lives of more than a hundred thousand Americans for the first time ever. It was a major jump in lives lost, and opioids accounted for about two-thirds of them.
Dr. Thomas Stopka: I can't say that it totally surprised me, especially given the increase in the previous report from the federal government, where there was a 30% increase from the prior year. And unfortunately we have seen things going in the wrong direction from the beginning of the Covid pandemic.
Reed Pence: That's Dr. Thomas Stopka, Associate Professor of Public Health and Community Medicine at Tufts University. His research has focused on opiate overdoses.
Dr. Thomas Stopka: Is it disheartening, frightening, and really sad and scary to see? Yes, absolutely. I hope and wish we can begin to go in the other direction. We just have to pull out all the options, think creatively and comprehensively about a response. The Covid-19 pandemic certainly didn't help and maybe greatly exacerbated the current situation with mental illness. That includes your substance use disorder and opioid use disorder. Now is the time to invest adequate support, to try to bring about change.
Reed Pence: Especially in the early days of the pandemic, stress, fear and chaos were everywhere. And that's bad enough if you're living what you'd consider a normal life, but it's the worst possible situation for people trying to deal with a mental illness or drug addiction.
Dr. Thomas Stopka: We had so much uncertainty and so many signs and displays in the news of severe illness, hospitalization, and death... And growing awareness of inequities, morbidity, and mortality patterns. The pandemic closed off so many services to us. Access to healthcare broadly became quite limited when it comes to routine appointments and for people receiving medications for opioid use disorder, for instance—initially, there was uncertainty as to how folks should approach. their typical visits to an opioid treatment program or to a methadone maintenance program. Or to a doctor's office where they would typically get a prescription renewed and refill for buprenorphine.
Dr. Thomas Stopka: Supply chain disruptions hit other drug users too. Again, especially in the early days of the pandemic. Stopka says many illicit drug users had to buy from people who were unfamiliar, some paid with their lives.
Dr. Thomas Stopka: If people are not able to get access to their typical supply, there's even more uncertainty in what it is that they're purchasing. And throughout the country right now, the fact that fentanyl is so prominent, not only in presumed opioid purchases, but also in presumed stimulant purchases: methamphetamine, cocaine, for instance. Folks often can be surprised. And when their tolerance for opioids is very low, particularly for people who solely use cocaine and methamphetamine, the risks for overdose are even further exacerbated.
Reed Pence: However, as the pandemic wore on, it wasn't an across-the-board disaster for opioid users.
Dr. Thomas Stopka: The Covid pandemic had some silver linings when it comes to access to medications for opioid use disorder, right? Because early on it didn't make sense for patients inclusions to meet in person and potentially increase the risk of Covid exposure and transmission. So the fact that methadone maintenance programs, and the fact that buprenorphine prescribers we're able to relax some of the typical requirements—because the federal government relaxed some of those requirements—was a silver lining in that people could now more easily get access to take-home doses. Then they wouldn't have to go to a methadone maintenance clinic every day, or every week if that's the stage that they were at in their treatment. And you know, the sky didn't fall when these regulations were relaxed.
Reed Pence: Over the last decade, prescriptions for opioid painkillers have also been pulled back. So fewer people might get started on opioids.
Dr. Thomas Stopka: There have been substantial decreases over the past decade. There have been some fluctuations, minor fluctuations in recent years, but many states like Massachusetts have put pieces of legislation in place that limits the number of opioids that can be prescribed. Such that less than a 30-day prescription in Massachusetts, seven days or less, depending on the procedure or the clinician who's being seen. So those types of policies have helped to dramatically reduce prescription opioid rates, in general.
Reed Pence: But those laws cutting opioid prescription sometimes have unintended consequences as well. If a person has been receiving illegal opioids for a long time and they're suddenly cut off, Stopka says the risk can be substantial.
Dr. Thomas Stopka: The withdrawals from opioid use disorder don't disappear overnight. And when one is in the throes of withdrawal, they're experiencing some of the worst sickness that they've ever experienced. Imagine the worst flu you could ever experience, and the worst intestinal bug you can experience, and the worst aches and pain altogether. Opioid withdrawal causes severe pain and discomfort. And so if someone has been receiving opioid prescription from a clinician for a long period of time, and if there's an interest among clinicians and amongst patients to reduce those opiate prescriptions, it has to be a conversation between the patient and between the clinician, and a taper reduction in order to reduce the risks of withdrawal. And therefore, potential risks for overdose when one wants to get unsick.
Reed Pence: Discussions are vital before users get cut off, or if doctors have plans not to prescribe an opiate in the first place after surgery. More and more physicians try for non-narcotic painkillers first, but patients need to know it ahead of time. Most of them figure they'll be getting an opioid.
Dr. Luke Elms: In fact, up to 80% of them, or right close to it, expect to be prescribed an opiate. Almost 70% of patients are willing to discuss non-opioid management, but that a significant portion of them, over 50%, are more concerned with adequate pain control after surgery than they are with the risks of addiction. And that's not unreasonable.
Reed Pence: That's general surgeon, Dr. Luke Elms of Orlando Health Dr. P Phillips Hospital in Orlando, Florida.
Dr. Luke Elms: If it's implemented poorly, and we just go out and we take away opioids and we don't replace it with a viable alternative that provides adequate pain control, that really hurts us in two ways: One, that that's cruel, and that's kind of against a lot of the tenants of what we're trying to accomplish as physicians. And two good luck getting that patient to really have a discussion regarding non-opioid management in the future, if their first exposure is someone just removing the opioid but not giving them adequate pain control. It is completely reasonable next time to really be hesitant to think about that as an option.
Reed Pence: Elms says as the opioid epidemic has become more well-known these kinds of discussions are much easier. However, patients may view post-surgical pain treatment a little differently than doctors do. Telling patients they'll be on Tylenol and ibuprofen can leave doctors open to the claim they're not taking pain relief seriously anymore. So Elms admits, some convincing needs to go on.
Dr. Luke Elms: 100%. Yes. I mean, absolutely. I think that's where the part of the conversation arises. Where you really point out that yes, you're right, because they are right. If they have a major surgery and they take just Tylenol over-the-counter at the doses that they may take over-the-counter and the way that they take it over-the-counter it's probably not going to be enough. And so, you know, you have to really tell them like, listen, we're prescribing the ibuprofen at a dose that, while it is just more of the over-the-counter medication, that the tablet is only available as a prescription for the amount that we prescribe. And it has an anti-inflammatory effect at that dosage.
Reed Pence: Not all patients are eligible for opiate-free pain relief, and not all of them achieve it, even after they try. Some are allergic to ibuprofen or acetaminophen. Those with bipolar disorder or an alcohol, tobacco, or substance use disorder, are also among those at risk of failure. But the number of people who get through surgery needing narcotic pain relief is much higher than those would explain, and that doctors would like.
Dr. Luke Elms: There are studies that show 9% of patients that receive opioids after a surgical procedure are going to still be taking them at 120 days after surgery. And I think that most of us in the surgical community would say that having an opioid needed at 120 days after surgery is well beyond when we would consider it a problem. I think that, uh, we know that from some of the studies that in patients with the risk factors I described, those numbers could be as high as 20%.
Reed Pence: Elms says what's important is changing how medicine thinks about opiates without demonizing the medication or the patient. Those going in for surgery, who used to get opioids first, now might get them only as rescue medication. But some people still need narcotics. For them, it would be cruel and dangerous to pull them too quickly.
Dr. Luke Elms: Opioids aren't necessarily the evil of the whole thing. It's using them when we don't necessarily have to. And I think that there are people out there that are in chronic pain, that are in need of these. And we need to treat these people compassionately, because at the end of the day, if we're just leaving people in uncontrolled pain, that's cruel. And it really runs against the whole purpose of what we're here to do. And so I think that we have a great opportunity to at least start a discussion. About multimodal pain control, as maybe a shift in the way we view pain and try to really cut down on the number of patients that are exposed. At the end of the day, if you get a patient off of opiates sooner than you would have before, or maybe you don't have to refill that prescription, that's a success. 1% improvement is a 1% improvement of exposure. 1%, you know, less people down the line that potentially are overdosing. And that 1% matters.
Reed Pence: Education, access, and communication may be the most important factors in reducing the opioid epidemic. For example, methadone management programs are not common in many rural areas. And Stopka says naloxone, which counteracts potentially fatal overdoses, needs to be much more widely available.
Dr. Thomas Stopka: That would help to facilitate getting naloxone out into communities in great need that may not have adequate access. And to ensure that family members, peers, friends, who have loved ones who are in the throes of opioid addiction could have naloxone on-hand, and be adequately trained and educated in how to use that to rescue people, who might otherwise suffer fatal overdose.
Reed Pence: Changing our mindset on opioid drugs would take us a long way in the right direction. As Elms has said, we demonize the drugs and the user now. For most other medical conditions, we don't. So what do we need? Better messaging of opioid use disorder as a disease, and an understanding that we have to treat that disease in the same way that we have to treat diabetes or heart disease or asthma. There's a biological component, and a social component, to addiction as a disease. And it's not the same for everyone. But we have to be able to provide just, and respectful, and dignify preventive and curative services to people who are fighting the disease of addiction.
Reed Pence: You can find help for addiction anywhere in the U.S. at 1-800-662-4357. That's 800-662-4357. You can find out more about all of our guests on our website, radiohealthjournal.org. I'm Reed Pence.
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