Fighting the Opioid Epidemic in Our CommunityBy Chad M. Brummett, MD, and Kristin Bennett Sep 26, 2016
Chad M. Brummett, MD
Opioid use and abuse in the United States has received considerable attention recently. Despite only constituting 4.4% of the world’s population, the U.S. consumes 80% of the world’s opioids. In 2012, there were 259 million opioid prescriptions, which is enough for one bottle of opioids for every adult in the U.S. It is believed that 78 Americans die every day from opioid-related overdoses. Although opioids are commonly prescribed for acute and chronic pain, there are no data to suggest that opioids are efficacious in the long-term management of chronic pain. Instead, the morbidity and mortality of chronic opioid use appears to far outweigh any of the potential benefits.
Concurrent with the rise in opioid use and abuse, heroin abuse has increased dramatically. The low cost of heroin compared to prescription opioids has, in part, driven this change. In the last decade, adolescent and adult abuse of heroin has increased by 63% and heroin-related deaths have increased by almost 300%. It is estimated that almost 75% of the new heroin users begin by abusing prescription opioids, unlike heroin use from decades past in which abusers began with heroin.
Postoperative Opioid Prescribing
Recently, the Centers for Disease Control (CDC) released guidelines for the prescribing of opioids for chronic pain that directly relate to the practice of the chronic pain physicians in the ASRA community. Whereas the new CDC guideline discusses the safe and appropriate prescribing of opioids for long-term management of chronic pain, there is little of the guideline devoted to postoperative opioid prescribing. This obvious gap is in part due to the fact that there are essentially no data to inform appropriate postoperative opioid prescribing.
Despite only constituting 4.4% of the world’s population, the U.S. consumes 80% of the world’s opioids.
Opioids remain the primary treatment for acute postsurgical pain. Recent guidelines have encouraged the use of nonopioid analgesics and regional anesthesia where possible, but opioids are still the primary analgesic provided following discharge from surgery centers or hospitals. Recent studies demonstrate a wide variance in postoperative prescribing patterns and note that opioids are commonly prescribed for minor surgeries and dentistry.[6,7] As there are no normative data to inform appropriate postoperative opioid prescribing, it is believed that prescription practices are largely driven by convenience. The goal of physicians is to ensure that patients have more than enough opioids to treat their postoperative pain without requiring additional visits or calls to the clinic or emergency department visits. In most centers, however, postoperative pain management is not a formal part of the preoperative education and the prescriptions are often nebulous (eg, “1-2 tablets every 4-6 hours as needed for pain).” The expected duration of use is seldom discussed. Therefore, patients are left to determine when and for how long to take opioids, and their decisions are often shaped by personal experience or that of a friend or family member. If the entire prescription is not needed, patients find themselves with a bottle of leftover pills. Few pharmacies will accept leftover controlled substances, and flushing opioids can have a detrimental environmental effect. Leftover opioids are frequently stored unsecured in medicine cabinets and are therefore accessible to adolescents and teens for future misuse and abuse.
Teen and Adolescent Opioid Abuse
As opioid use has increased in the U.S., so has the prevalence of opioid abuse in teens and adolescents. Prescription medicines are now the most commonly abused drugs by 12 and 13 year olds, and an estimated 90% of addictions start in the teenage years. Although some teens misuse or abuse medications previously prescribed for injuries or surgeries, the majority of teen abusers obtain the medications from a friend or family member. Many teens believe that opioids are safer than other drugs of abuse because they are prescribed by a physician. Sadly, many teens and young adults turn to heroin when they lose access to opioids or when opioids become too expensive.
Reducing Leftover Opioids in Our Community
Several years ago, our research team created a mission statement and guiding principles, including service to our community. We have and continue to proudly work with an incredibly well-organized local food pantry; however, we recognized the opportunity to create a new volunteer initiative that was closer to the work that we do every day. Although our group does not specifically study opioid abuse, we do have interest in the efficacy of opioids postoperatively, persistent use after surgery, opioid-induced hyperalgesia, and the behavioral factors associated with persistent use despite a lack of efficacy. As a group of anesthesiologists, psychologists, surgeons, and pain researchers, the opportunity to reduce the amount of opioids in our local community seemed like a natural fit for our group. The idea for an opioid recovery drive followed a lecture by Joseph Rannazzisi (deputy assistant administrator, Office of Diversion Control, Drug Enforcement Administration [DEA]) at the ASRA 13th Annual Pain Medicine Meeting in 2014. Mr. Rannazzisi described our current problems with opioids as being worse than the crack cocaine epidemic of the 1980s. We could see that immediate action was needed to reduce access to leftover opioids for adolescents and teens in our community.
To date, we have held three Saturday morning opioid drives. In just 12 hours, we have made a tremendous impact by reducing the number of opioids in our community. Combined, we have thus far collected ~140,000 pills, including more than 13,000 opioid pills and patches (Table 1). Following the first drive, we began tracking the dose of the opioid pills to quantify the opioids collected. In the last two drives, we collected more than 100,000 oral morphine equivalents. Surgery was the most common reason for the opioid prescriptions Additionally, we have collected approximately 15,000 antidepressants, benzodiazepines, sleep aids, muscle relaxants, and anti-epileptics. The total weight of just the pills and patches (not the bottles) from one 4-hour drive was almost 97 pounds. Amazingly, some of the prescriptions had been sitting in a medicine cabinet unused since the 1980s and early 1990s. Most importantly, we have drawn attention to the problem and created dialogue among healthcare providers, parents, teachers, police, and policy makers.
How Can You Start an Opioid Recovery Drive in Your Community?
Starting an opioid recovery drive is a terrific way to give back to your community while also enhancing the sense of community within your team. We have created a website with some information necessary to begin. Although this information is intended to help get you started, you should involve your community’s law enforcement early to ensure compliance. Communication and advertising are keys to success. Please let us know about your experience and share anything you learn along the way.
Our group remains committed to providing a safe place for patients to dispose of unused opioids. Ultimately, we believe that disposing of unused opioids should be much easier, and we will continue to push our politicians and policy makers to fix this issue. We are hopeful that our group will soon need to find a new community service effort when disposing becomes as easy as filling an opioid. Until that time, we will continue to partner with the police and our community to reduce the potential for opioid misuse and abuse.
We sincerely appreciate the City of Ann Arbor Police Department, specifically Sargent Thomas Hickey, Lieutenant Matthew Lige, and Officers Renee Bondy and Rebecca Provancher for their partnership and commitment to our community and the take-back events. Our vision of a drug-free community is possible with their involvement and leadership.
- Centers for Disease Control and Prevention (CDC). Drug overdose deaths in the United States hit record numbers in 2014. Atlanta, GA: CDC. Available at: http://www.cdc.gov/drugoverdose/epidemic/. Accessed April 24, 2016.
- Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015;162:276-86.
- Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: Demographic and substance use trends among heroin users - United States, 2002-2013. MMWR Morb Mortal Wkly Rep 2015;64:719-25.
- Centers for Disease Control Prevention (CDC). CDC guideline for prescribing opioids for chronic pain. Atlanta, GA: CDC. Available at: http://www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed April 24, 2016.
- Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016;17:131-57.
- Baker JA, Avorn J, Levin R, Bateman BT. Opioid prescribing after surgical extraction of teeth in medicaid patients, 2000-2010. JAMA 2016; 315:1653-4.
- Wunsch H, Wijeysundera DN, Passarella MA, Neuman MD. Opioids prescribed after low-risk surgical procedures in the United States, 2004-2012. JAMA 2016; 315: 1654-7.
- McCabe SE, West BT, Boyd CJ. Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study. J Adolesc Health 2013;52:480-5.
- Partnership for Drug-Free Kids. http://www.drugfree.org. Accessed April24, 2016.
- Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med 2016;374:154-63.
- Brummett CM, Janda AM, Schueller CM, et al. Survey criteria for fibromyalgia independently predict increased postoperative opioid consumption after lower-extremity joint arthroplasty: A prospective, observational cohort study. Anesthesiology 2013;119:1434-43.
- Goesling J, Moser SE, Zaidi B, et al. Trends and predictors of opioid use following total knee and total hip arthroplasty. Pain 2016; 157:1259-65.
- Wasserman RA, Hassett AL, Harte SE, et al. Pressure pain sensitivity in patients with suspected opioid-induced hyperalgesia. Reg Anesth Pain Med 2015;40:687-93.
- Goesling J, Henry MJ, Moser SE, et al. Symptoms of depression are associated with opioid use regardless of pain severity and physical functioning among treatment-seeking patients with chronic pain. J Pain 2015;16:844-51.
Chad M. Brummett, MD, is the associate chair of Faculty Affairs, director of Clinical Anesthesia Research, and director of Pain Research, and Kristin Bennett is an administrative assistant senior, both in the department of Anesthesiology, divison of Pain Medicine, at the University of Michigan Medical School in Ann Arbor.
Note: This article originally appeared in the ASRA News, Volume 16, Issue 3, pp. 6-8 (August 2016).