Use and Overuse
It’s an all-too-familiar story: an otherwise healthy individual suffers chronic pain following an injury or surgery. Attempting to manage the pain, a doctor prescribes an opioid, a class of highly effective yet potentially addictive narcotics that includes codeine, hydrocodone, oxycodone and morphine. Over time, the individual’s use becomes more frequent and the dosage needed for an effect increases, as do other problems related to the opioid such as misuse of the medication and physical dependence.
As more and more individuals find themselves trapped in habits of overuse, opioids are diverted from legally prescribed, controlled use into a widespread illegal marketplace serving both pain patients experiencing addiction and recreational users, all seeking to meet their growing dependence, too often with tragic consequences.
Low income individuals are more likely to struggle with addiction, and they’re also more likely to be impacted by the changes brought about by healthcare reform. That provides a real window of opportunity to study how we can make addiction treatment and other mental health services more effective and accessible than ever before.– Mark Ilgen, Ph.D., whose work aims to develop and evaluate interventions to prevent suicides linked to substance use
The pattern of opioid use, abuse, addiction and overdose presents a significant and growing public health threat. According to the Centers for Disease Control and Prevention (CDC), opioid prescriptions have quadrupled since 2000; during the same period, the rate of opioid overdoses has tripled. Opioids including heroin were involved in 61 percent of all drug overdose deaths, making them the most common substances involved in overdoses in the U.S.
While not every prescribed opioid sets this heartbreaking pattern in motion, more and more do. To stem the tide, IHPI members are working to break a number of links in the chain. Their work is yielding potent evidence-based interventions and policy recommendations.
There is an opportunity to have a tremendous impact and save lives right now, if we act on what the research has shown can work.– Amy Bohnert, M.H.S., Ph.D., who has helped develop a toolkit to reduce prescription opioid misuse among emergency department patients at risk for overdose
How much is too much?
IHPI member-investigator Amy Bohnert, M.H.S., Ph.D., is helping providers determine how much is too much. Bohnert, an assistant professor the U-M Department of Psychiatry, is also a member of the VA Center for Clinical Management Research and the U-M Injury Center. An epidemiologist, she specializes in studying opioid use and abuse. “Now that we know a problem exists, we need to step back and reconsider whether giving these medications for long periods of time is the best treatment course for all patients with chronic pain. We need to draw a clearer line between controlling pain and setting people up to overdose.”
Bohnert led a comprehensive study of data on opioid use and accidental overdose among veterans. It revealed for the first time that the threshold for safe dosing may be lower than most people think – or than most prescriber guidelines recommend. “Our study compared records of veterans who died from accidental opioid overdose with those who took opioids for chronic pain but did not overdose,” explains Bohnert. “We found that those prescribed higher doses of opiates were more likely to die of an overdose.”
“Our findings suggest that changing prescribing practices to avoid escalating doses could make a major difference in the number of patients who die,” she continues. “Avoiding prescribing large doses also reduces the risk of larger dose pills falling into the hands of others, like children and teenagers.”
As a result of this and related studies, the VA has amended their prescribing recommendations for opioids. The CDC is pursuing a similar path, tapping Bohnert to be part of the core expert group developing the guidelines.
Another IHPI member, Mark Ilgen, Ph.D., is focused on a different but equally tragic end point for too many opioid users – suicide. A clinical psychologist and associate professor in the Department of Psychiatry, Ilgen pairs a clinical focus on chronic pain and addiction with research conducted through the VA Health Services Research Group.
Ilgen was first author on a study of nearly 124,000 veterans revealing that those receiving the highest doses of opioids for pain were more than twice as likely to die by suicide (including suicide by any means, not just by intentional overdose) than those receiving the lowest doses.
While Ilgen acknowledges that much more work is needed to truly understand suicide risk, this study points to two important signposts: “First, unresolved chronic pain on its own is a strong risk factor for suicide. Second, when it comes to suicide, we’re not seeing evidence that opioids taken to manage that pain protect against suicide. In fact, the opposite appears to be true: higher doses of opioids place individuals at higher suicide risk.”
For providers, Ilgen’s work encourages providers ask more questions before they prescribe. "Patients in pain are a group at elevated risk for suicide. So as providers, we need to be vigilant about asking about mental health symptoms—including directly asking about or screening for suicide risk, and thinking about referrals and risk management for these patients."
Overprescribing opioids after surgery
Each year more than 50 million surgeries are performed in the U.S., and most of those patients receive a postoperative opioid prescription. Shortly after surgery, most patients can switch to a non-opioid medication like ibuprofen or acetaminophen to help control any lingering pain. Yet if patients are prescribed too many opioid pills, they may not limit their use to surgical pain, using them for other pain, for mood disorders like depression, or even as sleep aids. This pattern of misuse can eventually lead to abuse. In addition, many who discontinue their opioids postoperatively fail to safely dispose of their remaining pills, making them available to children, family and friends for diversion and abuse.
Despite the well-documented risks of opioid overuse and dependence, until recently, there were no guidelines to help doctors determine how many pills to prescribe following surgery. IHPI investigators, in partnership with surgeons, have developed the Opioid Prescribing Recommendations for Surgery, a new online tool to help surgical teams that perform nearly a dozen common operations prescribe these powerful medications more wisely.
The CDC estimates 78 people die every single day from opioid- or heroin-related overdoses. That’s like a plane full of people crashing every week. – Chad Brummett, M.D., who is leading efforts to improve prescribing practices within the state of Michigan
IHPI aims to disrupt the epidemic of prescription opioid addiction now affecting all age groups from our nation’s youth to the elderly through early intervention—that is, by using a preventive approach that draws on robust networks of providers to systematically improve prescribing practices and thereby reduce the unintended opioid distribution into our local communities. Michigan OPEN is an IHPI-supported effort to prevent surgery-related opioid addiction by analyzing and sharing information about opioid prescribing patterns in the state and by helping hospitals learn how to hold drug take-back events in their community. By heading off this problem at the source of prescription, the initiative aims to prevent the misuse of these powerful drugs within our state, and share knowledge that can help other areas throughout the country facing similar challenges.