Recent estimates showing that 100 million Americans suffer from pain explain the highly common and increasing use of opioid analgesics. Between 1991 and 2011, a nearly 200% dispensing increase for this category of pain reliever occurred. Unfortunately, the complex problem of prescription drug abuse is an escalating issue, and has become a serious public health concern in the U.S. With cases of opioid overdose on the rise, new products such as Evzio (naloxone hydrochloride injection), which is intended for the emergency treatment of known or suspected opioid overdose, are becoming crucial.
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Deaths from opioid overdoses have soared to nearly 17,000 annual occurrences in recent years. The rate of deaths from drug overdoses where opioids, alone or in combination with other drugs or alcohol were involved, jumped to nearly 60% in 2010, a notable increase compared to the 30% reported in 1999. The misuse or abuse of opioid analgesics accounted for 420,000 visits to emergency departments in 2011, representing an increase of 114% in such visits from 2004. A six-fold increase in substance abuse treatment admission rates for opioid analgesic abuse occurred between 1999 and 2010. Economic consequences are also substantial; when accounting for the cumulative costs of criminal justice expenses, substance abuse treatments, and loss of work productivity, studies have estimated annual totals of $53–$56 billion related to opioid abuse.
A number of factors contribute to making opioid analgesic abuse a complex problem. Most opioids are prescribed by only a small percentage of providers and are taken by a similarly small percentage of patients, who are in turn the individuals who are at the greatest risk for overdose. High-volume prescribers are more likely to write prescriptions for patients who overdose on opioids. Sometimes patients with legitimate prescriptions share or do not store or properly dispose of prescription drugs. This issue, as well as the clinical practices of providers; insufficient oversight to control inappropriate prescribing; risk mitigation strategies not followed by providers; pharmacy benefits and insurance policies; and an erroneous belief by many that there is not a danger associated with prescription drugs, which causes an increase in their use, can all further complicate and accelerate the problem of abuse.
Unfortunately, adequate treatment is often an unmet need, since opioid analgesics are centrally involved in prescription abuse. Education and awareness about appropriate opioid prescribing can vary greatly among specialties, which contributes to the issue. Compounding this is the fact that new opioid formulations, revised clinical guidelines, and new information on opioid risks (such as increased overdose risk at higher doses) are all very recent developments. Up-to-date information and training for providers in all specialties is crucial. The availability of new opioid products and technical advances in drug delivery offer more choices for prescribers (see Opioid Products table, based on FDA-approved labeling [as of February 2014] as part of the 2015 PDR Nurse's Drug Handbook ) and will aid in providing adequate, appropriate therapy for those who need it.
Guidance such as the following American Academy of Pain's Statements on the Use of Opioids for the Treatment of Chronic Pain offers useful input when addressing pain management:
- Legislation and regulatory policies should limit inappropriate prescribing but should not discourage or prevent prescription of opioids where medically indicated and appropriately managed.
- Prescription of opioids for chronic, intractable pain is appropriate when more conservative methods are ineffective and the treatment plan is reasonably designed to avoid diversion, addiction, and other adverse effects.
- Physicians should be sensitive to and seek to minimize the risks of addiction, respiratory depression and other adverse effects, tolerance, and diversion. However, some commonly held assumptions about these issues need to be reviewed.
- Opioids should be prescribed only after a thorough evaluation of the patient, consideration of alternatives, development of a treatment plan tailored to the needs of the patient and minimization of adverse effects, and on-going monitoring and documentation.
Now healthcare providers can prescribe Evzio (naloxone hydrochloride injection), a new hand-held auto-injector to reverse opioid overdose, which can be used to treat a person known or suspected to have had an opioid overdose. This is a revolutionary example of the type of product available; in general, naloxone drugs require administration via syringe and are most commonly used by trained medical personnel in emergency departments and ambulances. Evzio is the first naloxone treatment specifically designed to be given by family members or caregivers. Evzio is not a substitute for immediate medical care, and the person administering Evzio should seek further, immediate medical attention on the patient's behalf.
PDR Network is a valuable resource for opioid antagonists such as this, as well as thousands of available products, offering alerts and specific product labeling. Keep current by using PDR.net and by providing updated contact information. If you use the electronic health record channel, please ask for it to include PDR drug data feeds, including PDR BRIEF. Updated drug information, full labeling, and safety warnings will be integrated into your electronic prescribing system automatically, and at no cost to you.
Salvatore Volpe, MD, FAAP, FACP, CHCQM
Chief Medical Officer