Plague of painkiller deaths requires swift collective fight

Deaths from accidental overdoses of opiate pain medicines have more than quadrupled in the new millennium and currently outnumber deaths from heroin and cocaine. Drivers include intensive marketing on the part of big pharma and illegal access to prescription drugs on the street. The magnitude of the epidemic has spurred action throughout the health care industry and on the part of government. Crucial to safe and effective treatment of chronic pain is a multidisciplinary approach that systematically addresses physical, social and psychological issues.

Seventy-eight patients in the U.S. die daily from opiate overdoses, according to the National Institutes of Health, Center for Disease Control. Nearly half a million people have died from drug overdoses since 2000. President Barack Obama’s administration recently escalated its efforts to curb opioid abuse through prevention and treatment which build on a proposal for $1.1 billion dedicated to this issue.

This includes almost $100 million released from the Department of Health and Human Services to fund 271 Community Health Centers to address opioid disorders. The Substance Abuse and Mental Health Services Administration (SAMHSA) recently received an $11 million funding opportunity for treatment services. Those with dual diagnoses of substance abuse and mental health problems are a critical population. Both diseases must be treated in concert.

This academic year, roughly half of U.S. medical schools began requiring students to take some form of prescriber education, consistent with the recently released Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain.

Manakai o Malama continues to offer individual provider education and case conferences at multidisciplinary team meetings. Responsible treatment depends on a comprehensive intake and careful diagnostic work-up to identify sources of pain and establish a treatment plan. At Manakai, pain patients are also screened by a clinical psychologist and are typically treated by one of our occupational therapists focusing on life management skills. Every effort is made to manage physical pain and mental health without relying on opioid medications. Additional resources include injections, management of sleep apnea, physical therapy, acupuncture, chiropractic and medical massage.

The Hawaii Opioid and Overdose Leadership Action (HO‘OLA) Workgroup represents leadership across health industry sectors on the islands dedicated to using the evidence to develop and implement policy to address the statewide epidemic. Among their signature issues is an effort to encourage health plans to support increased use of nonopiate integrative treatment for chronic pain to include more extended services for physical and occupational therapy and to increase services for acupuncture, chiropractic and medical massage. There is also a strong interest to ensure that carriers, especially Quest and Medicaid, cover adequate services for relevant behavioral health. In addition, HO‘OLA advocates removal of pre-authorization obstacles for important inpatient care for opiate withdrawal and for important medications including naloxone, which is an effective antidote in opiate overdose.

In Hawaii far too many patients follow down a similar path. It often begins with a mild to moderate musculoskeletal injury that is treated with pain medicine intended for temporary use only. Physical therapy services, which in the past were more readily available, are now relatively limited. The patient remains less mobile and slowly becomes more dependent on pain medications. The pain and inactivity affect the ability to work, and one becomes more vulnerable to depression, obesity and sleep apnea. The sleep apnea resulting from the obesity, and the opiates that reduce the drive to breathe, are a set-up for an overdose. All it takes are some extra pain meds on a bad day combined with a few drinks.

As a nation, and as a state that offers some of the best health care in the country, we share a collective responsibility to address the growing problem of opiate drug overdoses. The solution begins with adequate resources for education and treatment. Responsible care includes a comprehensive work-up, a patient pain contract, multidisciplinary care and ongoing, meticulous monitoring. Much remains to be done to heal our precious community from this vexing epidemic.

Ira “Kawika” Zunin, M.D., M.P.H., M.B.A., is a practicing physician. He is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.