By Dr. Karyl Rattay
While the COVID-19 pandemic has overtaken most people’s awareness, deaths from suspected drug overdoses continue to occur at high numbers.
As of June 6, 160 people have died in our state from a suspected overdose this year. Delaware has made some progress in reducing the number of overdoses from prescription drugs. Prescribing rates for opioids in Delaware decreased by 25% between 2013 and 2017.
Still, the Centers for Disease Control and Prevention ranks Delaware first in the nation for the rate of high-dose, long-acting opioid prescriptions written. The CDC also ranks Delaware second in the nation for its rate of overdose deaths. Three out of four people who use heroin misused a prescription opioid first, according to the Centers for Medicare and Medicaid Services.
Co-prescribing opioids and benzodiazepines remains all too common. The combination can be deadly, as both drugs suppress breathing. Controlled substances can also be deadly on their own. Prescription Monitoring Program records from the Drug Overdose and Mortality Surveillance Report, Delaware, 2017, show that 80% of those who died from a drug overdose were prescribed a controlled substance. The study also shows that of those who died, females and those who are white, older and highly educated were more likely to have been prescribed a controlled substance.
The use of opioids to help patients manage chronic pain has increased significantly in the past two decades. However, recent studies have shown that other therapies are more effective and less likely to lead to misuse. To reduce the overprescribing of opioid medications, I am urging all Delaware health care providers to consider nonopioid pain-management therapies first.
Acetaminophen; nonsteroidal anti-inflammatory drugs (NSAIDs); and, when appropriate, gabapentin, tricyclic antidepressants (TCAs) and serotonin norepinephrine reuptake inhibitors (NSRIs), along with topical agents, are all medications that should be considered before prescribing opioids to manage pain.
Evidence in recent clinical trials also suggests that certain nonpharmacological pain-management modalities, including physical therapy, exercise therapy, chiropractic care, acupuncture, yoga, massage and cognitive behavioral therapy — often in combination — are effective and successful in mitigating chronic pain. We know that managing patients’ chronic pain is challenging, but we want to make it easier for providers to safely help patients. That’s why we developed an entire section on helpisherede.com for health care providers. The provider section offers more than 30 information factsheets, as well as pain and risk assessments, consent form examples, algorithms for prescribing, patient education handouts and many other materials.
Providers can download materials or order printed copies free of charge, to share internally and incorporate into their practices. We have also added new materials specific to nonopioid pain-management options, which were mailed to providers in April.
We also encourage providers to follow the recommendations below, which are based on those issued by the CDC:
• Educate patients and their families about the risks of using opioid medications.
• Increase the use of evidence-based tools available on helpisherede.com.
• Register for and use the Delaware PMP as required by law.
• Assess each patient’s risk for misuse or abuse of opioid medications in the PMP by reviewing patient history for multiple prescriptions, prescriptions written by multiple providers and dangerous co-prescribing of opioids and benzodiazepines.
• Prescribe opioids only when absolutely necessary and limit quantity and dose.
• Before prescribing opioids, consider nonopioid pain-relief medication options and nonpharmacological pain-management therapies, such as physical therapy, chiropractic care and yoga.
Combating this epidemic is a priority. Behind the data are real people, whose lives are forever changed by addiction. Opioid addiction affects a wide array of individuals, from high school athletes to blue-collar workers to highly educated professionals. Without ongoing treatment, lives are turned upside down when substance use disorder leads to joblessness, homelessness, unintended pregnancy, crime, health problems and the disintegration of family relationships.
Providers are the key to saving Delawareans’ lives. By looking at prescribing practices more closely, considering nonopioid alternatives to chronic pain management and taking advantage of available resources, we can help stem the tide of addiction. We look forward to partnering with providers to mitigate this crisis.
Karyl Rattay, MD, MS, is the director of the Division of Public Health at the Delaware Department of Health and Social Services. This Commentary was originally published in the July/August 2020 Delaware Medical Journal. Copyright 2020 by the Medical Society of Delaware.