HJAR Jul/Aug 2022

DRUG ADDICTION 16 JUL / AUG 2022 I  HEALTHCARE JOURNAL OF ARKANSAS   spondylosis — in layman’s terms, arthritis of the lumbar spine. The patient looked in surprisingly decent shape, not the classic morbidly obese patient that meets the pro- file of someone suffering with chronic pain. That struck me as odd, but I gave him the benefit of the doubt. When I asked himwhat was wrong, he pointed at his lumbar area close to L3-4, beside the spinal processes. When I touched him, he almost fell to the floor grimacing and almost yelling in pain. He was on the verge of tears. We were pre- scribing oxycodone with Tylenol 10/325 mg, three a day. He convinced me to give him a few extras due to the pain that, accord- ing to him, had started that morning after a weird move when he was leaving his bed. “It is unbearable,” he said. I fell for it. I prescribed oxycodone with Tylenol 10/325 mg at 3 to 4 a day as needed for pain, and I gave him 105 pills — 15 more than the three a day, which would have been a total of 90. I told him that, usually, this kind of event subsides in about 72 hours (or three days), but on his next visit, we would try to wean him off because he was a young person in pretty good shape who would most likely do better if he could stick to a regular exercise program and get off the opioids. Well, fortune was on my side. I needed to renewmy medical license that day and had to go to my car to get my wallet to pay for it online. To my surprise, I sawmy “patient” jumping and goofing around with one of his friend’s, waving the prescription that I had signed a fewminutes earlier while they were crossing the street! The next day, without knowing that I saw him, he was at the front window demanding to see me because the pharmacist told him that I had canceled the prescription. I asked the receptionist to call me because I wanted to talk to him as soon as he showed up. It did not take long to get rid of him. When I mentioned the police, the guy practically vanished. Sadly, stories like mine, I am sure, happen every day all over the country, and we are not lucky enough to catch them all the time. More “prescription” opioids are being bought on the black market, often through social media or e-commerce websites. These pills are usually counterfeit, made in Mexico or China, and contain fentanyl and methamphetamine. 10 Another important point: The dosage and the number of tablets prescribed matters. Communities with higher opioid prescrib- ing rates experience higher drug overdose rates, even among individuals who are not prescribed opioids. 11 THE MEDICAL COMMUNITY DECIDES TO ACT Once the numbers started to resonate, it was imperative to use any resort at hand to control or at least mitigate the opioid epidemic. Numbers like 417,601 overdose deaths since January 2015; like in 2017, 75,000 Americans died for the same cause; over 93,000 overdose deaths in 2020, up by 30% from 2019 and the highest death rate ever recorded! 9 Deaths from the Vietnam War and AIDS pale in comparison to the statistics above. To be more specific, during the Vietnam War (1955-1975), a total of 58,220American service members died. The highest annual death rate attributed to AIDS was 43,000 in 1995; thankfully, by 2016, this death rate dropped to 6,721. 9 In our state of Arkansas, overdose deaths in 2020 are estimated to have increased by more than 40%, or 152 deaths, according the CDC National Center for Health Statistics, up from 363 in 2019 to 515. This confirms that Arkansas’ increase is higher than the national average, though all states’overdose deaths increased during that time period. Arkansas Drug Director Kirk Lane said officials knew the overdoses would be higher in 2020 because of the COVID-19 pandemic. “People with depression, iso- lation, all those factors that go into a per- fect storm, but also we had a great influx of illicit fentanyl in the state,” Lane said. ‘We are seeing that in all sorts of substances, whether pressing it into counterfeit pill, meth, cocaine and even marijuana.” Lane noted that Fentanyl became the deadliest drug inArkansas in 2020, surpass- ing methamphetamine. 12 With this off-the-chart data, the pain medicine subspecialty, working in con- junction with the CDC, state medical boards, pharmacies, and the regulatory institutions, developed a task force to use any means available to mitigate the opioid epidemic. It was noted that patients, after undergo- ing surgeries, were being prescribed exces- sive opioids by their doctors and surgeons to treat postoperative pain. One of the changes to improve this practice and to help dimin- ish the abuse of opioids was to emphasize the use of acetaminophen, NSAIDs, and an extremely limited number of tablets and at lower MME’s (morphine milligrams equiv- alent) — in other words, from prescribing opioids for a whole month down to a week. The multimodal approach to pain manage- ment using various other methods is proven to be extremely effective in controlling pain. NSAIDs, acetaminophen, regional anesthe- sia (e.g., nerve blocks), and local anesthetic delivery pumps are all viable alternatives, as well as Cognitive Behavioral Therapy (CBT) and Physical Therapy (PT). It was also clear that, depending on the surgical procedure, the postoperative pain would have a different intensity. It would be less painful to recover from a minor sur- gery compared to an open-heart surgery, for example. In the past, it was common to prescribe the whole monthlong regimen to either one. Stratification of the surgical pro- cedures was key in the decision making to determine what amount and dose of opioids were going to be necessary. It’s when patients receive excessive amounts of opioids following surgery that directly impacts their chances for develop- ment of chronic opioid use, opioid misuse, and development of opioid use disorder. And what happens to the unused opi- oids? Seventy-five percent (75%) of patients stored them in an unlocked location, increasing the chance of potential use by another member of the family; 85% did not dispose of unused opioids; and 69% did not