Now in the shadow of COVID-19, opioid misuse is another long-term health crisis that has killed over 450,000 people in this country since 1999.
According to National Institutes of Health data, every day, 128 people in the U.S. die after overdosing on opioids. The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare.
Now in the shadow of COVID-19, opioid misuse is another long-term health crisis that has killed over 450,000 people in this country since 1999. The Centers for Disease Control and Prevention estimates that the total “economic burden” of prescription opioid misuse in the U.S. alone is $78.5 billion a year, including the costs of health care, lost productivity, addiction treatment and criminal justice involvement.
With the establishment of the Rothman Orthopaedic Institute Foundation for Opioid Research and Education, Jefferson Health and its department of orthopedics have joined the battle against the opioid crisis like never before. Orthopedics is a specialty particularly prone to inadvertently contributing to the opioid crisis. Spearheaded by its president, Dr. Asif Ilyas, the Rothman Opioid Foundation is dedicated to funding and advancing research and education aimed at finding solutions to the opioid epidemic.
On a separate front, Jefferson established its Opioid Task Force in the fall of 2017 to provide structure, focus and direction to the health system’s response to the ongoing opioid crisis. The Opioid Task Force established a Controlled Substances Prescribing Practices policy, encompassing the prescription of Schedule II/IIn, Schedule III/IIIn and Schedule IV controlled substances—with an emphasis on the regulation of opioid prescription for pain management. The policy also encompasses prescription of any other drug the prescriber determines to pose an abuse or diversion risk.
“The overarching drive to this policy is to prescribe opioids only when they are necessary,” says Richard Pacitti, PharmD, director of Pharmacy Services for Magee Rehabilitation Hospital – Jefferson Health and co-chair of the Opioid Task Force’s Policy Subcommittee. “There are a lot of rules and regulations, guidance and direction on how to responsibly prescribe opioids.”
According to the U.S. Department of Health and Human Services (HHS), the opioid epidemic can be traced to the late 1990s, when pharmaceutical companies reassured the medical community that patients would not become addicted to opioid pain relievers, and healthcare providers began to prescribe them at greater rates.
Increased dispensing of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed be highly addictive. In 2017 HHS declared a public health emergency and announced a 5-Point Strategy to Combat the Opioid Crisis.
“We recognize that opioid-related abuse, diversion and deaths are serious problems, both in Philadelphia and nationally,” Dr. Ilyas says. “From the perspective of musculoskeletal medicine, it’s a specialty that is prone to contributing to this problem and we have to be pro-active to prevent that.”
Dr. Ilyas speaks from personal experience. Several years ago, he treated a young college student with a wrist injury that required surgery. The surgery went as planned and the young man recovered uneventfully. A year or so later, he saw his patient’s mother for an issue that she was having. When he inquired about how her son was doing, she said he had recently passed away from opioid abuse.
“I was just blown away,” Dr. Ilyas recalls. “She was very matter of fact and said the surgery on his wrist got him hooked on opioids, it spiraled from there and he recently passed away. I was left shocked and speechless.”
Unfortunately, it’s not an uncommon story. The fact that nearly 130 people die every day from an opioid-related overdose is a devastating phenomenon caused by opioid diversion, addiction and abuse that has become the leading cause of accidental deaths in America.
“Imagine a patient is prescribed 50 tablets of oxycodone after an orthopedic procedure and that patient uses 10 tablets,” Pacitti says. “That bottle with the remaining tablets sits in a medicine chest and they’ve got young children who turn into teenagers and they go digging around in a drawer and they find it. All of a sudden there is a potential for misuse, diversion and harm.”
The objectives of the Rothman Orthopaedic Institute Foundation for Opioid Research and Education is threefold:
The Foundation is primarily focused on prevention strategies, Dr. Ilyas says, “Because as prescribers, that’s where we are focusing. Our logic is, that if we can work to prevent overprescribing, then treatment for abuse and addiction will be less of an issue over time.”
Jefferson’s Controlled Substances Prescribing Practices policy states that the decision to prescribe controlled substances “should be made only after the provider completes a full medical examination, reviews the patient’s medical history and assesses the patient’s risk for addiction.” Providers should consider using a standardized tool for assessment of a patient’s risk for addiction, the policy says, and the corresponding medical record must contain a medical diagnosis consistent with the prescription of a controlled substance for pain management.
On the education front, the Rothman Opioid Foundation is funding a series of preoperative opioid counseling studies focused on educating patients on the safe use of opioids. Similar studies are investigating the impact of intra-operative and postoperative strategies on opioid use. Preoperative strategies, Dr. Ilyas notes, focus on educating the patient on safe use of opioids.
Before a patient has a hip replacement, spine surgery or carpal tunnel release, can we educate them so they become more informed about the use of opioids, their benefits and risks, and then, they can understand when to take them, when not to, and how to get off of them right away.—Dr. Ilyas
Recent Rothman studies, Dr. Ilyas says, have shown a 50-66% reduction in voluntary opioid usage postoperatively. “We are now embracing that and rolling out formal preoperative education before surgery for all patients.”
Intraoperative research funded through the Foundation is examining the effects of nerve blocks and opioid-sparing interventions administered during surgery, including local and systemic non-opioid medications that can decrease a patient’s pain experience, thereby reducing the need for opioids post-surgery.
Post-operative research is focused on evidence-based opioid prescribing strategies. “What we’re finding in our research is that there has historically been a really high, inadvertent over-prescribing of opioids,” Dr. Ilyas says. Physicians are prescribing as many as 30 pills on average, with patients in many cases consuming as few as 10 or even five pills. “That leaves 20 to 25 pills unused,” Dr. Ilyas says, “and the problem with unused opioids is that they’re now available for diversion or abuse. So it’s not necessarily that patients of ours will abuse it; someone else can also get their hands on it.”
The research is helping physicians “tighten up” opioid prescribing by studying how many pills patients typically consume following specific procedures. “We shouldn’t be giving the same amount of opioids if you’re doing a carpal tunnel release, versus a hip replacement, versus a multi-level spinal fusion,” Dr. Ilyas says. “We should be able to adjust those to the specific amounts relative to those procedures.”
The Foundation is also working with the Jefferson College of Population Health to develop a portable opioid prescribing curriculum that will be offered to medical and dental schools across the country. Students will be able to complete the curriculum in the classroom, or online, as a series of vignettes depicting different prescribing issues. The scenarios include inpatient, post-operative and cancer patient opioid prescribing, as well as overviews about the management of an opioid overdose and how to comply with state regulations for opioid prescribing. “So when these kids are graduating, they’ll already know how to prescribe opioids,” Dr. Ilyas says. “I can tell you that when I graduated medical school 20 years ago, there was no such education.”
There are plans for the program to be made available to physician assistant and nurse practitioner programs as well, Dr. Ilyas says.
At Magee Rehabilitation Hospital, where pharmacist Pacitti serves as its director of Pharmacy Services, a number of non-pharmacologic therapies are used to reduce pain and minimize the risk of opioid abuse – everything from treating pain with ice, to massage therapy and acupuncture. Magee therapists also specialize in distraction therapies such as art and horticultural and music therapies. And of course, there are two therapy dogs to help patients maintain a sense of calm. “All of those non-pharmacologic interventions work in conjunction to serve as distraction mechanisms, reducing the need for opioids to treat pain, minimizing opioid overuse and potential abuse,” Pacitti says.