Between a rock and a hard place: prescription opioid restrictions in the time of fentanyl and other street drug adulterants.
A long-standing body of scientific literature characterizes problematic substance use as a chronic and relapsing neurobiological disorder (3) that is exacerbated by social and economic deprivations. (4) Despite this knowledge, stigma and misconceptions of addiction endure among some healthcare professionals which affects the quality of care for patients with substance use disorders. (5) In addition, the evidence- practice gap has resulted in morality-based law enforcement strategies that remain the predominant response to substance use and repeatedly fail to achieve meaningful progress.
WHAT IS HAPPENING NOW
Although the failing "war on drugs" has consistently demonstrated that supply reduction policies often result in perverse unintended consequences that severely undermine public health and safety, the principles of supply reduction are being expanded to opioid prescribing in numerous jurisdictions in order to prevent the initiation of NMPOU and diversion of POs. Given the powerful withdrawal symptoms and cravings associated with opioid use disorders, however, prescribing restrictions may not have the intended effect among those who experience these symptoms and are compelled to seek out relief. Individuals who cannot acquire POs due to limited availability or cannot use POs via their preferred route of administration due to abuse deterrent formulations may resort to a substitute drug; indeed, research findings link PO supply reduction measures in the United States with transitions from POs to street drugs such as heroin among some at-risk groups. (6,7) In an era of increasing adulteration of street drugs with fentanyl, related analogues and new synthetic chemicals, these risks are particularly concerning.
Although POs are only effective for treating certain types of pain, (8) the issue of pain management is entwined with NMPOU, given that those who engage in NMPOU frequently report pain relief as a motivation for use. (9) However, current prescribing guidelines recommend non-pharmacological therapies for treating pain, which many health care systems are not equipped to provide or which require substantial out-of-pocket expenses. (8) In addition, research on the benefits of medical cannabis is lagging, despite the potential for medical cannabis to be substituted for PO use (10) and to decrease PO-related emergency room admissions. (11) Consequently, sanctioned pain treatment can be very difficult to access, and this disproportionately affects at-risk groups such as older adults and those who have low incomes. This paradox is consistent with the inverse care law, where people who are most vulnerable and in need of health care services are less likely to receive adequate health care than the general population.
WHAT NEEDS TO CHANGE_
Considering the well-established characteristics of substance use disorders, harms associated with supply reduction policies, and importance of effectively managing pain, the current policy focus on restricting POs is too narrow. In addition to these restrictions that reduce NMPOU incidence and PO diversion, parallel efforts to care for those already engaging in NMPOU are critical for avoiding the unintentional consequences of decreasing the supply of POs and increasing risk of exposure to adulterated street drugs. A comprehensive approach to NMPOU is needed that addresses the realities of both the NMPOU epidemic and substance use disorders, and introduces policy reforms that improve access to non-pharmacological pain treatments. These broader policy solutions may include physician-specific policies and scaling-up evidence-based harm reduction services.
To address NMPOU, physicians should use prescription drug monitoring databases and safe prescribing practices, such as urine drug screen tests and treatment agreements. Physicians who learn of patients engaging in NMPOU, however, should continue providing the best medical care for those patients instead of immediately discontinuing POs. Regimen non-compliance or NMPOU should trigger an intensification of services for these patients, which may include assistance with tapering off POs, and facilitating access to opioid agonist treatment and other harm reduction services as appropriate. Heroin-assisted treatment programs are also feasible for treating individuals who do not respond to traditional opioid agonist treatment therapies and require higher treatment intensity. (12) In addition, emergency department protocols for managing opioid withdrawal may provide an important entry point for engaging patients who use POs non-medically in care. Although innovative solutions such as these are necessary for addressing NMPOU, novel programs or policies often lack expansive evidence bases to guide implementation in new settings. There is considerable evidence, however, affirming addiction as a chronic and relapsing medical condition that requires long-term treatment (13) and wraparound services. (14)
Efforts to reduce enduring barriers to opioid agonist treatment and expand other programs with strong evidence bases, such as drug consumption rooms, drug testing services, needle exchanges, and naloxone distribution, are also important. Despite numerous challenges to implementing them successfully, (15) harm reduction strategies are effective in many settings for helping people with substance use disorders maintain engagement with health care services, reduce potential harms such as fatal overdoses, and facilitate linkages to other services, including treatment. This approach has been successful precisely because it addresses the realities of substance use disorders without moralizing or stigma. Unfortunately, these programs are largely absent from mainstream health care and remain chronically underfunded as services for a relatively small and marginalized section of the population. The ubiquity of NMPOU and the rise of fentanyl, however, expose the need to better integrate harm reduction services within health care systems, expand anti-poverty programs, reduce addiction-related stigma among health care professionals, and give serious consideration to decriminalizing or legalizing all illicit drugs.
It is clear that physicians who prescribe and do not prescribe POs are caught in ethical dilemmas where they risk "doing harm" regardless of their decision. Despite a clear need to reduce PO prescriptions, comparable attention to closing the evidence-practice gap and implementing a comprehensive response to NMPOU beyond supply-reducing efforts is important. Given the realities of substance use disorders and emergence of fentanyl and dangerous adulterants in street drugs, broader policy solutions will reduce the risk of pushing vulnerable citizens further to the margins and provide a meaningful response to this epidemic.
(1.) National Advisory Committee on Prescription Drug Misuse. First Do No Harm: Responding to Canada's Prescription Drug Crisis. Ottawa, ON: Canadian Centre on Substance Abuse, 2013.
(2.) Alexander GC, Frattaroli S, Gielen AC (Eds.). The Prescription Opioid Epidemic: An Evidence-Based Approach. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health, 2015.
(3.) Leshner AI. Addiction is a brain disease, and it matters. Science 1997; 278(5335):45-47. PMID: 9311924. doi: 10.1126/science.278.5335.45.
(4.) Rhodes T, Lilly R, Fernandez C, Giorgino E, Kemmesis UE, Ossebaard HC, et al. Risk factors associated with drug use: The importance of 'risk environment'. Drugs Educ Prev Policy 2003; 10(4):303-29. doi: 10.1080/ 0968763031000077733.
(5.) van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug Alcohol Depend 2013; 131(1-2):23-35. PMID: 23490450. doi: 10.1016/j.drugalcdep.2013.02.018.
(6.) Dart RC, Surratt HL, Cicero TJ, Parrino MW, Severtson SG, Bucher-Bartelson B, et al. Trends in opioid analgesic abuse and mortality in the United States. NEngl J Med 2015; 372(3):241-48. PMID: 25587948. doi: 10.1056/NEJMsa1406143.
(7.) Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry 2014; 71(7):821-26. PMID: 24871348. doi: 10.1001/jamapsychiatry. 2014.366.
(8.) Guerriero F, Reid MC. New opioid prescribing guidelines released in the US: What impact will they have in the care of older patients with persistent pain? Curr Med Res Opin 2017; 33(2):275-78. PMID: 27786538. doi: 10.1080/ 03007995.2016.1254603.
(9.) McCabe SE, Boyd CJ, Cranford JA, Teter CJ. Motives for nonmedical use of prescription opioids among high school seniors in the United States: Self-treatment and beyond. Arch Pediatr Adolesc Med 2009; 163(8):739-44. PMID: 19652106. doi: 10.1001/archpediatrics.2009.120.
(10.) Lucas P, Walsh Z. Medical cannabis access, use, and substitution for prescription opioids and other substances: A survey of authorized medical cannabis patients. Int J Drug Policy 2017; 42:30-35. PMID: 28189912. doi: 10. 1016/j.drugpo.2017.01.011.
(11.) Shi Y. Medical marijuana policies and hospitalizations related to marijuana and opioid pain reliever. Drug Alcohol Depend 2017; 173:144-50. PMID: 28259087. doi: 10.1016/j.drugalcdep.2017.01.006.
(12.) Rehm J, Gschwend P, Steffen T, Gutzwiller F, Dobler-Mikola A, Uchtenhagen A. Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: A follow-up study. Lancet 2001; 358(9291):1417-20. PMID: 11705488. doi: 10.1016/S0140-6736(01)06529-1.
(13.) McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA 2000; 284(13):1689-95. PMID: 11015800. doi: 10.1001/ jama.284.13.1689.
(14.) McLellan AT, Hagan TA, Levine M, Gould F, Meyers K, Bencivengo M, et al. Supplemental social services improve outcomes in public addiction treatment. Addiction 1998; 93(10):1489-99. PMID: 9926553. doi: 10.1046/]. 1360-0443.1998.931014895.x.
(15.) Mancini MA, Linhorst DM, Broderick F, Bayliff S. Challenges to implementing the harm reduction approach. J Soc Work Pract Addict 2008; 8(3):380-408. doi: 10.1080/15332560802224576.
Received: January 27, 2017
Accepted: April 29, 2017
Tessa Cheng, MPP,[1,2] Kora DeBeck, MPP, PhD[1,3]
[1.] British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC
[2.] Faculty of Health Sciences, Simon Fraser University, Burnaby, BC
[3.] School of Public Policy, Simon Fraser University, Burnaby, BC Correspondence: Tessa Cheng, Simon Fraser University, Research Associate, Urban Health Research Initiative, B.C. Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Tel: 604-806-9142, E-mail: firstname.lastname@example.org
Conflict of Interest: None to declare.
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|Author:||Cheng, Tessa; DeBeck, Kora|
|Publication:||Canadian Journal of Public Health|
|Date:||May 1, 2017|
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