Abuse of Prescription of Narcotics in Primary Care Essay
Abuse of Prescription of Narcotics in Primary Care Essay
Chronic non cancer pain in primary care and use of opioids (Nicholson Pasik, 2007).In the USA estimates suggest that 50 million people suffer from chronic non cancer pain, with 41% dissatisfied with the outcomes of their pain treatment. The frequent site at which these patients seek health care is from primary care. In the primary care environment prevalence of chronic non cancer pain ranges from 5% to 33% (Nicholson Pasik, 2007).3) Extent of opioid misuse in primary care and causes (Von Korff et al, 2011). True estimates of the extent to which prescription opioids are misused among primary care patients are not available, but the limited evidence from surveys conducted suggest that the prevalence of prescription opioid misuse in primary care could range from 4% to 26% (Von Korff et al, 2011)4) Primary care givers need to have adequate knowledge on preventing opioid misuse Salloum, 2010). Abuse of Prescription of Narcotics in Primary Care Essay. Though the true prevalence of prescription opioid misuse remains elusive the indications of high abuse of prescription opioids raises the relevance of prevention practices at the point of misuse (Ruiz Strain, 2010).B.Establish a working definition of prescription opioid abuse and identification of the characteristics of prescription opioid abuse1) According to Friedman et al p, 454, NUPM in a wide perspective may be taken to mean the use of a scheduled prescription medication without the prescribing clinician’s knowledge (Friedman et al, 2009).2) Characteristics of abuse of prescription narcotics (Liebschutz et al, 2010)… ry care patients diagnosed with chronic pain and prescribed opioids shows that the characteristics for PDUD in such patients include cigarette smoking, high severity of pain, personal and family history of substance abuse, post-traumatic stress disorder, and experience of a jail sentence (Liebschutz et al, 2010). 3) Caregiver knowledge and attitudes in the prescribing of narcotics for non cancer chronic pain (Srivatsava, 2007). Evidence coming from surveys conducted on care givers points to knowledge deficits in care givers and attitudinal issues acting as barriers to efficient management of pain. Quite often fear of addiction and misuse of prescribed narcotics is the basis of unsatisfactory management of pain (Srivatsava, 2007). 4) Patient perspective on prescribing of narcotics for non cancer chronic pain (Srivatsava, 2007). From the perspective of patients it is the care providers in the form of medical and nursing professionals that are knowledgeable on issues pertaining to employing narcotics in the treatment of pain, and they expect that these professionals provide them with the appropriate information on narcotics in the treatment of non cancer chronic pain, to make it a useful part in their treatment (Srivatsava, 2007).Abuse of Prescription of Narcotics in Primary Care Essay. II Theoretical Considerations (Not done as no guidelines received and not mandatory for the annotated outline) III Review of Literature A literature review matrix has been generated for effectively developing the literature review. 15 peer reviewed primary research articles relevant to the topic of the dissertation were selected. The inclusion criterion was that these articles were published on or later than 2006. The rationale behind such an inclusion criteria was to make the literature deliver the currently relevant body of knowledge on the
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Years of sustained, coordinated, and vigilant effort will be required to contain the present opioid epidemic and ameliorate its harmful effects on society. At least 2 million people have an opioid use disorder (OUD) involving prescription opioids, and almost 600,000 have an OUD associated with heroin (HHS, 2016). These numbers are likely to increase in the coming years, regardless of what policies are put in place. Follow-up studies of individuals receiving treatment for OUD involving heroin (e.g., Hser et al., 2001) find very high rates of premature mortality (in the neighborhood of one-third) due to overdose or other complications of the disorder. Thus, even if the nation ramps up treatment availability substantially and immediately, death rates will climb and quality of life will be dramatically reduced for many people for years to come.Abuse of Prescription of Narcotics in Primary Care Essay. Likewise, the continued progression of still more people from prescription opioid use to OUD will demand sustained and coordinated effort to establish and implement the scientifically grounded policies and clinical practices necessary to reshape prescribing practices and reduce the occurrence of new cases of prescription opioid-induced OUD.1
What should be done to contain the opioid epidemic and to prevent new cases of iatrogenic addiction and associated overdose, death, and other harms? The purpose of this chapter is to review available evidence on strategies that have been used to address the problems of opioid misuse, OUD, and related deaths. The chapter begins with prefatory sections addressing (1) the nature of the evidence on policies implemented at the jurisdictional level (typically a state or a nation), as opposed to clinical interventions operating at the level of an individual patient; and (2) the need for a systems approach, including the importance of recognizing the potential effects that interventions focused on misuse of prescription opioids have on misuse of opioids more generally. Next the chapter reviews the evidence on the effectiveness of strategies for addressing the opioid epidemic in four categories: (1) restricting supply, such as by regulating the types of products approved for use (e.g., abuse-deterrent opioids) and regulating/restricting conditions of lawful access to approved drugs; (2) influencing prescribing practices, such as through provider education and the issuance of prescribing guidelines; (3) reducing demand, such as by educating patients about opioids and increasing access to treatment for OUD; and (4) reducing harm, such as through provision of naloxone to prevent opioid overdose and needle exchange programs for people who use injection drugs. Abuse of Prescription of Narcotics in Primary Care Essay.
NATURE OF THE EVIDENCE
Theoretically, the comparative effectiveness of different opioid-related policies could be quantified through use of randomized controlled trials (RCTs). For example, consider a clinical strategy that eschews prescribing opioids to treat chronic noncancer pain if the patient scores high on a scale used to measure risk of developing opioid addiction. The effectiveness of this strategy for preventing OUD could be evaluated in an RCT in which patients were assigned to either that policy intervention or an alternative one with fewer restrictions on opioid prescription. An RCT is the preferred source of evidence for causal inference because the random assignment is expected to result in comparable groups of individuals assigned to each strategy. In a large RCT of different approaches to opioid prescribing for preventing OUD, for example, one would expect patients in each group to have, on average, the same risk factors for developing OUD. That is, any future differences between the groups in the frequency of OUD could be ascribed to the different treatment strategies to which they were assigned rather than to differences in the characteristics of the individuals receiving each strategy. As a result, the outcome distribution in each group could be interpreted as the counterfactual outcome distribution that would have been observed in that population under the corresponding strategy.2
RCTs, however, are rare for policies that require implementation at the level of an entire jurisdiction, nor are they ethically permissible in many policy contexts. In the absence of RCTs, other sources of evidence are needed to estimate the counterfactual outcome distribution under different strategies. One such source of evidence is the collection of data on individuals who happen to receive the strategies of interest as part of their routine care, often from electronic health records. Abuse of Prescription of Narcotics in Primary Care Essay.The so-called observational analyses based on such data are attempts to emulate the RCT that cannot be conducted (the target trial). In these observational analyses, however, the comparability of the groups receiving each strategy is not guaranteed. In the real world, for example, the restricted opioid prescription policy might more likely be applied to individuals visiting providers in urban health care settings who also received other interventions to reduce the risk of addiction. As a result, a direct comparison of the outcome distribution between those who received each strategy would be confounded by the concomitant interventions.
Observational analyses attempt to eliminate bias due to confounding by adjusting for all measured prognostic factors that are distributed differentially between the groups. For example, the comparison might be conducted separately among individuals in urban and rural health care settings. If all confounding factors are appropriately measured and adjusted for, the observational analysis will adequately emulate the target trial and correctly estimate the counterfactual scenarios under each strategy. But even if confounding is eliminated in an observational analysis, this source of evidence is inherently limited with respect to the counterfactual scenarios it can recreate. Analyses of observational data may be helpful for estimating the comparative effects of different treatment strategies applied to a clinical population, but may not capture population-level effects under different policies. For example, an observational analysis of patients of certain health care providers will not quantify effects due to scaling up a treatment strategy as a policy applied to the entire health system.
In fact, this chapter typically investigates the effects of strategies that operate at the level of a jurisdiction, such as a locality or state, or that of the country as a whole. Because random assignment is exceedingly rare in such circumstances (no one, for example, is authorized to randomly assign New Hampshire and 24 other states to receive one policy or to freeze policy in the other 25 states so they can serve well as controls), and observational analyses of clinical populations cannot capture system-wide effects (even if they could successfully adjust for confounding), other approaches are needed. All of these approaches will lack physical randomization of the strategies being examined and therefore will be subject to confounding, but they nonetheless are essential sources of evidence for estimating the effectiveness of various strategies. Abuse of Prescription of Narcotics in Primary Care Essay.
Before–After Comparisons
A common nonrandomized source of evidence is before–after comparisons, or the comparison of population outcomes before and after a strategy has been implemented in a single population. Because of underlying trends, however, this comparison may provide a biased estimation of the counterfactual scenarios. For example, the strategy might have been implemented in a population precisely because conditions in that population had been deteriorating. If the underlying factors that gave rise to this trend persisted, conditions might continue to worsen after the strategy was implemented even if the strategy was helpful because it diminished but did not reverse the rate of deterioration. Or the implementation process might move so slowly that the strategy did not take effect until the underlying problem had already exhausted its momentum, and a sort of regression to the mean thus created the illusion that the policy was more effective than it truly was. Therefore, a before–after comparison may not correctly identify the counterfactual of how the world would have looked in the absence of the strategy’s implementation.
Ecological Comparisons
Another nonrandomized source of evidence is ecological comparisons, or comparison of outcomes between two different populations, only one of which has received the strategy. Again, however, this comparison may provide a biased estimation of the counterfactual scenarios because the policy may have been implemented in one of the populations precisely because conditions had been deteriorating, or other important between-population differences in prognostic factors may have affected the outcome.
An additional challenge for nonrandomized sources of evidence is that many strategies may exert effects that extend across jurisdictional boundaries or manifest only with a considerable lag. For example, even a successful intervention might noticeably reduce the incidence of overdose only many years after being implemented. Indeed, some interventions that successfully reduced diversion of prescription opioids might, at least in theory, initially increase rather than decrease the number of overdose deaths, even if they reduced deaths in the long run, as the result of an initial surge in deaths among people already addicted to prescription opioids who turned to black market substitutes, whose potency is more variable. Furthermore, some intervAbuse of Prescription of Narcotics in Primary Care Essay.entions may have different effects depending on the metric employed; thus, for example, distributing naloxone might reduce the number of fatal overdoses but—particularly if there were some risk compensation or other behavioral adaptation—increase the total number of overdose events. Strang and colleagues (1999), for instance, found that 6 percent of individuals in treatment for opioid addiction who were interviewed (9 of 142) reported that access to naloxone might lead them to increase their heroin dosage.
Another problem is that of nonlinear response in systems that have their own internal dynamics. For example, resale or other diversion of prescription opioids by people who had already “traded down” to cheaper black market opioids might cause others to initiate misuse of prescription opioids, others who themselves might later trade down, divert, and supply still others. This problem is illustrated by the difficulty of talking about the number of cases of an infectious disease that are prevented per vaccination as if it were a universal constant, whereas that number in fact depends on the number of other vaccinations being given and the current prevalence of the disease.
THE NEED FOR A SYSTEMS APPROACH
A complementary approach to evaluating intervention strategies implemented at the jurisdictional level in systems with lags and nonlinearities is to use some model of the system in question to project what might be expected with and without the intervention of interest. This approach has been used in a variety of contexts, including air traffic control (Bertsimas and Patterson, 1998; Long et al., 1999; Terrab and Odoni, 1993), fisheries management (Bjørndal et al., 2004; Clark, 1990; Megrey, 1988), vaccination (Goldstein et al., 2005; Kaplan et al., 2002; Medlock and Galvani, 2009), and tobacco control (IOM, 2007, 2015; Levy et al., 2005), among many other important policy domains.
The dynamics of prescription opioid misuse are complicated, particularly when one takes into account the markets for diverted and purely illegal opioids, but a simple sketch helps clarify the value of a systems approach. A typical clinical trajectory that policy changes would like to prevent starts with medically appropriate use of prescription opioids, escalates to misuse and then to OUD, and then evolves to trading down to cheaper black market opioids before manifesting in overdose. Abuse of Prescription of Narcotics in Primary Care Essay. Thus, a leaky prescription drug system increases the flow of people into the state of having OUD. People tend to remain in that state for a very long time, an average of 10 to 20 years, with modest flows out of that state through overdose death, death from other causes, or permanent cessation of use.3
FIGURE 5-1
A systems model of the opioid misuse problem. SOURCE: Reprinted from Wakeland et al., 2015.
The number of overdoses per year might be roughly proportional to the number of people who currently had an active OUD, but this number would not be proportional to the current inflow of new people developing OUD, which is what many interventions aimed at controlling the misuse of prescription opioids would affect most directly. Those interventions would not instantly change the prevalence of OUD and hence would generally not have an immediate effect on overdose. By contrast, interventions that reduced the likelihood that an overdose would occur, or that it would be fatal, might reduce fatalities right away. A fair comparison of the effectiveness of interventions designed to reduce diversion with those designed to reduce the frequency or lethality of overdoses requires a true systems model, not just simple statistics. Wakeland and colleagues (2015) provide an example of such a systems model, reproduced in Figure 5-1.
Constructing such models is a major research endeavor in its own right, and the committee is unaware of any existing model that incorporates all of the strategies discussed in this chapter; therefore, the relative effectiveness of these strategies cannot be compared. Creating such models would have important advantages: it would guide and strengthen surveillance and research, foster a common policy vocabulary among all agencies with decision-making authority over opioid regulation and enforcement (federal, state, and local), and facilitate the exchange of information among them. Investing in research and possible development of such a model is worthy of consideration by the U.S.Abuse of Prescription of Narcotics in Primary Care Essay. Food and Drug Administration (FDA) and other agencies. In any event, since no formal systems model now exists, the committee provides an overview of the key conceptual features and implications of a systems approach (without a formal model) to identify some of the considerations that need to be taken into account in reviewing the possible impact of alternative strategies. However, empirical analysis of the various strategies reviewed in this chapter relies on the traditional statistical methods outlined in the previous section.
A Systems Approach to Opioid Misuse
The boundaries delineating governmental agencies’ respective responsibilities do not always align with the real boundaries of markets or behaviors concerning OUD and resulting overdose. While the FDA’s regulatory authority may give it a particular interest in reducing addiction and mortality caused by prescription opioids, the nation’s overall public health interest lies in reducing addiction and mortality caused by opioids of all sorts. A person with prescription opioid–related OUD may escalate his or her opioid misuse, and an overdose leaves a grieving family wondering whether or not the person’s last dose was obtained through a prescription.
Prescription and nonprescription opioids intertwine on both the demand and supply sides of the market because all opioids belong to one family of chemicals that operate on similar molecular pathways; the molecules bind to a neuroreceptor regardless of whether they are associated with a prescription. In addition, as shown in Chapter 4, the prescription opioid epidemic is interwoven with the illegal drug market. Therefore, this chapter considers policy options for reducing OUD, mortality due to opioid overdose, and other opioid-related harms among people who have ever used prescription opioids, rather than focusing exclusively on options for reducing misuse of or overdoses from prescription opioids alone.
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In the economic sense of the term, all opioids are substitutes (as opposed to complements) in the same sense that oil, gas, coal, nuclear, solar, and hydro are substitute sources of energy for producing electric power. Substitutes are not identical and interchangeable; a molecule of morphine is different from a molecule of fentanyl, just as a barrel of oil differs from a ton of coal. There are distinguishable groupings within broad families of substitutes. Abuse of Prescription of Narcotics in Primary Care Essay. Energy policy distinguishes fossil fuels from sources with lower carbon footprints; in this context, one can distinguish partial from complete opioid agonists. But just as one cannot develop a sensible response to global warming by changing only policies toward oil, one cannot develop a sensible response to the nation’s opioid problem by adjusting only policies concerning prescription opioids.
The central economic idea about substitutes is that people will tend to use more of item A and less of item B when the price of A falls relative to the price of B, where price is construed broadly to mean the total cost of obtaining and using the item. For opioids, that total cost includes not only the dollar price, but also the time and inconvenience of obtaining the drug and all relevant risks in terms of health and possible criminal justice sanctioning (Moore, 2013; Reuter and Kleiman, 1986; Rocheleau and Boyum, 1994). A related concept is substitution driven by changes in income; as people become poorer, they may substitute hamburger in place of steak and heroin in place of prescription opioids (Petry and Bickel, 1998). Abuse of Prescription of Narcotics in Primary Care Essay.
