Opium and opium-related products have long been recognized for the gift of their powerful pain-relieving qualities. Frequently though blessings prove to have their downsides. America is no stranger to pain medication crises as pharmaceutical companies have developed new and more powerful drugs to meet the needs of people in pain.
Laudanum of the 1800s was followed by the man-made opioid morphine, developed to help injured Civil War soldiers. Heroin, and later cocaine, were developed to cure morphine addiction. Now headlines are full of the threat of the new “Opioid Scourge.” Overdoses account for more than 45,000 American deaths per year, and in spite of policies implemented to stem the tide, so far no decrease is evident.
The current crisis with drugs such as tramadol, codeine, hydrocodone (Vicodin and Norco,) oxycodone (Percocet and Oxycontin), fentanyl, and other opioids began in the 1990. Government policies, promotion by pharmaceutical companies (particularly Purdue Pharmacy), liberalization in prescribing pain medication among physicians, and the availability of drugs like heroin from Mexico all were contributing factors.
You may be wondering why I am writing about this topic in a column devoted to senior issues. And in Chico? Isn’t this mainly a problem of the Midwest and of young adult addicts?
No, it isn’t. I was surprised by the statistics shared with me by Dr. Phillip Filbrandt of Rehabilitation Medication Associates and the Butte-Glenn Medical Society’s liaison to the Butte County Drug Abuse Task Force. The rate of opioid prescriptions in Butte County is two times higher than the California average and three times the national average.
Butte County also has a higher than average opiate overdose death rate. For two years, Butte County was No. 3 in the state for drug deaths per capita; now it is in the top 10. About half of those deaths are caused by illegal drugs like heroin and half by prescribed medication. Sometimes the overdose is due to taking too many pills and other times for taking the prescribed amount in combination with other substances like alcohol, barbiturates, and muscle relaxants.
Age demographic data shows the 55 to 59, and 70 to 74-year-olds have the highest number of opioid overdose deaths in Butte County, about 30 deaths per 100,000 residents. So now you see why the Opioid Epidemic is a topic suitable for a column on senior issues for Butte County.
With increased awareness of the devastation that can be caused by misuse or overdose of these powerful narcotics, the government agencies, drug companies, pharmacies, and physicians are reversing earlier policies and looking for ways to insure that opioids are used minimally and responsibly.
Just as the problem has many contributors, the solution will require help from many sources. Lawsuits blaming drug companies for helping trigger the current opioid epidemic have caused a main offender, Purdue Pharmaceutical, to stop marketing Oxycontin to doctors. Insurance companies and pharmacies are regulating prescription amounts and frequency of refills and keeping track of multiple opioid prescriptions.
Governmental agencies are devoting funds to programs intended to help fight the opioid crisis. California has instituted CURES (California Utilization Review and Evaluation System) an electronic database that tracks controlled substance prescriptions in the state.
Physicians and pharmacists must check the CURES online database before prescribing opioids to patients. It tells patient’s name, medications they have received, who has prescribed them, which pharmacy they use, and when and how many pills they have received. Contiguous state-to-state sharing of information is being worked on so people can’t just cross state lines to get more drugs.
Hospital emergency rooms have traditionally been besieged by opioid addicts seeking drugs. Butte County hospitals have banded together to prevent this by adopting countywide policies which are publicized on posters in the ERs.
Policies include requiring that patients must have only one provider and one pharmacy and that information will be checked and recorded on the CURES system. Only a limited amount of pain medication will be given, shots for flare ups of chronic pain will not be given, “stolen” or “lost” prescriptions will not be refilled, missed doses of Suboxone or Methadone will not be provided, and long-acting pain medications such as OxyContin, MSContin, Fentanyl, and methodone will not be prescribed by the ER.
Physicians are doing their part by focusing both on treatments for those patients who are already addicted and on ways to keep others from becoming addicted by limiting their exposure to opioids.
For those who have developed opioid medication dependency and want to “kick the habit” physicians can prescribe Suboxone, a helpful treatment for those with substance abuse disorders. Dr. Filbrandt finds it “a good program for the right patient,” one who will cooperate with using the drug in conjunction with exercise, counseling, good nutrition and sleep, and control of other medical conditions.
Suboxone is a combination of two drugs: buprenorphine and naloxone. Buprenorphine has some effect on pain but it also keeps the receptors for the opioid occupied, preventing withdrawal symptoms or cravings. Naloxone (brand name Narcan) counteracts the effects of morphine.
Naloxone can also be used for people in danger of dying from opioid overdoses. It does not require a prescription and comes in two forms: nasal spray and an injection similar to the epipen used for life-threatening allergic reactions.
Dr. Filbrandt feels that anyone taking doses of opioids, prescribed or illicit, should keep naloxone on hand to prevent overdose for the patient or a child or pet who might accidentally ingest a dropped pill. Through a grant, the Butte County Drug Abuse Task Force has been able to acquire doses of naloxone to be distributed to key locations with high-risk patients, such as Butte County Behavioral Health and the Butte County Public Health Department.
While younger people may get started on the road to addiction by stealing pills from Grandma’s medicine cabinet for recreational use, older people often become “accidental addicts,” falling into the spiral of opioid misuse because they are routinely prescribed these medications for pain due to deteriorating physical conditions like arthritis, injuries, or surgery.
Some hospitals are successfully keeping older patients with hip fractures off opioids by using the ERAS (Early Recovery After Surgery) protocol. Before surgery, as soon as patients are admitted to the ER, they are given an intravenous drip of Tylenol in conjunction with a Bupivicaine nerve block in the hip area. Patients have fewer drug-induced side effects and recover more quickly.
Additionally physicians are rethinking approaches to routine pain management. A recent study by Dr. Erin Krebs, a researcher with the Veterans Affairs Health Care System, has shown that for patients with chronic back, hip and knee pain from arthritis, opioids worked no better than over-the-counter drugs like Tylenol, ibuprophen and prescription non-opioids for nerve or muscle pain.
However, Dr. Filbrandt point out that “the challenge of any medical study is that it tells us general things, but it doesn’t tell you if your patient in the office fits in that generalization.” Opioids are a real blessing for patients who require them. Physicians must recognize which patients can rely solely on alternative medications and treatments and those who have pain from conditions like end-stage cancer, chronic neuropathy, or severe degeneration of joints from rheumatoid arthritis for which access to opioids is essential.
A long-time Chico rheumatologist expressed worries to me that new opioid prescription restrictions from government agencies, insurance companies, and pharmacies might interfere with availability of necessary medications for his patients who need opioids to relieve agonizing pain and allow them some mobility. Dr. Filbrandt concurs: “Despite the frenzy about opioids, there are people who need this pain medication … We don’t want to abandon these patients in our effort to stem this epidemic.”
For patients who need opioid prescriptions, Dr. Filbrandt feels it is essential to identify those with chemical and psychological factors that predispose them to addiction. They should be monitored much more carefully than those who do not have this problem.
The next column will focus on medical interventions that can provide pain relief for many sufferers.
Leslie Howard is a retired English teacher and certificated gerontologist. She welcomes comments and suggestions at leslie.t.howard@gmail.com.
