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CDC Announces New Opioid Prescribing Guidelines; Naloxone Pen Distribution is Best Life Saver

2016-03-18

There has been a big controversy over the release of the new guidelines by the Centers for Disease Control (CDC) but it seems to be an over-reaction.  The guidelines advise that Vicodin or Norco are not first-line treatment for acute pain, nor for mild chronic pain.  The guidelines do allow for some patients to use some quantities of opioids, but with caution.  There is no  prohibition on using opioids when a patient has severe, chronic, noncancer pain.  The condition must be evaluated and properly diagnosed; efforts to correct orthopedic problems that cause wear and tear with chronic inflammation are very important.

If a patient has pain, it must be controlled well enough to continue with the activities necessary to daily living.   Going to work is necessary for many people, and if it causes pain that can’t be controlled with non-steroidal anti-inflammatory drugs, then sometimes hydrocodone is necessary.  The problem is that there are many people who say they have pain, who really don’t have significant pain.  There are other people who have started taking opioids and are dependent on them, even though they don’t have significant pain.

The primary care provider, the receptionist, and the nurse take the brunt of patient demands for opioids.  The patient is sure to be dissatisfied if their demands are not met.  In some cases, the patient may become violent and there are stories about patients brandishing firearms in their efforts to get drugs.  I know of more than one fatal shooting that occurred because the patient demanded, and was denied, a common narcotic pain killer.

What is just as bad, is the overdoses.  The number of fatal opioid overdoses has increased by 200% since 2000 and is now at a record level, parallel with the increase in prescriptions and sales of narcotics.  The exact mechanism for the increase in overdoses is not completely clear, but it appears that patients sometimes take an unexpectedly potent form of a known drug such as heroin, or take a larger than normal dose because of prior shortage.  Perhaps the overdoses are in part intentional and reflective of a suicidal predisposition; that possibility has not been completely ruled out.

According to the CDC’s Morbidity and Mortality Weekly Report for January 1, 2016, there has been a dramatic rise in overdose deaths due to fentanyl because of the production of illicit fentanyl by underground chemists.  In 2014, there were 47,055 deaths from all drug overdoses, exceeding deaths from motor vehicle crashes by one and a half times.  There were significant increases in death rates in both sexes, all age groups, ethnic groups, and regions of the country.  West Virginia had the highest rate of deaths from drug overdoses.   61% of drug overdose deaths were from all opioids, including heroin.  Heroin overdose death rates increased 26% in one year and have more than tripled since 2010.

It seems that heroin use has also increased dramatically in the last few years and that the biggest factor in the increase has been the transition from prior use of prescription opiates.  The relative cost of heroin and its high purity has contributed to the patients’ switches from prescription to illicit opioids.  Illicit fentanyl has also been available and is sometimes mixed with heroin.  Pure heroin and fentanyl are probably contributing to accidental overdoses due to product potency.

The fact that the quantity of opioids prescribed has increased four times since 2000 has a great deal to do with the epidemic of opioid overdose deaths.  Patients receive significant amounts of drugs from doctors but are eventually cut off or find the drugs inadequate, so they switch to heroin.  The high quality, nearly pure heroin cheaply available on the street is satisfying the desire to “get high” but puts the user at risk of accidental overdose.

Illicit fentanyl is being mixed with high purity heroin and sold as “China White”; since fentanyl is 50 times as potent as morphine, the chance of overdose increases further.

Based on this reasoning, the single action most likely to reduce overdose deaths is the widespread distribution of naloxone injectable pens to addicts, emergency workers, and anyone else who is likely to run into a patient who has overdosed.  Naloxone can temporarily reverse the respiratory suppression caused by overdose and could save the life of a patient who has lapsed into a coma and stopped breathing after using too much heroin or fentanyl.

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