As May comes to a close, COVID-19 had killed nearly 100,000 Americans so far this year. This must clearly remain the focus of public health policy. But there is another epidemic that used to make headlines: opioid overdoses. These two crises feed each other in deadly ways. We’re desperately seeking new tools to fight COVID-19 — from vaccines to antivirals to technology — but we already have underused tools to fight opioid deaths. 

Almost 50,000 people died from opioid overdoses in 2018. The Health and Human Services inspector general concluded, “The 2020 COVID-19 pandemic makes the need to look at this population even more pressing.”

COVID likely detrimental to mental health

The COVID-19 pandemic tragically fuels the root causes of the opioid crisis, including depression, unemployment, poverty, social alienation and many other “conditions of despair.” Some research suggests that every 1 percentage point increase in the level of unemployment translates into a 3.6% increase in the opioid death rate. If the pandemic increases unemployment rates by 10-20 percentage points, this could generate a staggering increase in opioid deaths that would compound the tragedy.

But beyond there is another set of institutional factors that may cause the COVID-19 pandemic to worsen the opioid crisis, and that’s the change in the way we access health care. Thirty-two percent of opioid overdoses are from legally prescribed drugs such as oxycodone — roughly the same share as from heroin. Some of the deaths from legally prescribed drugs are in patients who take them for legitimate pain management. These patients need help to prevent abuse and death. Some deaths are in individuals using medications prescribed for someone else. This diversion is deadly. 

Telemedicine is playing a vital role in providing access to health care during the pandemic — but it may paradoxically have the unintended consequence of accelerating these overdose deaths. Telemedicine is an important way to keep vulnerable patients out of health care facilities where they could pick up — or spread — disease. At both the state and federal levels, reimbursement and other rules have changed to encourage telemedicine, including allowing the prescription of opioids — even across some state lines. Approximately 76% of U.S. hospitals report that they are now connecting with patients using video, audio, chat, email and related technologies.

Telemedicine could be causing dangerous side effects

These new measures have the potential to increase opioid abuse, diversion and death. Without a face-to-face encounter, a physician has limited ability to evaluate the condition of a patient seeking pain management. And one of the few policy tools available to check for patients “opioid shopping” by going to multiple providers — state-level prescription drug monitoring programs (PDMPs) — does not work across state lines. It seems like we are already experiencing COVID-19’s impact on opioid overdoses, with multiple reports showing a sharp local increases in opioid deaths.

What should we do to mitigate this compounding death toll?

Of course, limiting the economic consequences of the COVID-19 pandemic through unemployment benefits and small business support is crucial on multiple fronts. But there are also much lower cost avenues that can help to forestall a rise in overdoses without limiting access to much needed care. State-level prescription drug monitoring programs must be strengthened, integrated into a national system and more easily accessed by prescribers. There are new technologies available to support desperately needed pain management while limiting the potential for diversion and overdose, including sophisticated pill tracking.

Policymakers can enable and incentivize adoption of new technologies in the same way that they have spurred adoption of telemedicine.

The COVID-19 crisis is unlikely to resolve quickly, and expanded access to telemedicine may be a boon for underserved patients even after it passes. We have tools available to mitigate the consequently higher risk of opioid overdoses without limiting access to needed care and medicines. If we act quickly, we can ensure that one public health crisis doesn’t further fuel another. We need to protect our communities from further hardship as best we can — particularly hardships so easy to forecast and to prevent.

A new study shows that people with opioid use disorder who enter inpatient medically managed withdrawal treatment (detox) do not usually receive further treatment, including medication for opioid use disorder or additional inpatient treatment. Those who did receive further treatment with medication (methadone, buprenorphine or naltrexone) or residential treatment were more likely to survive to 12 months. Published in Addiction, this study emphasizes the importance of keeping people with opioid use disorder engaged in treatment in order to increase their chances of survival. 

Inpatient medically managed withdrawal – detox – is one of the most common ways that people with opioid use disorder (OUD) seek treatment. While people enter detox with the goal of getting better, many do not engage in additional treatment specific to their OUD, including with medication, after discharge. Without ongoing medication for OUD, they leave detox with reduced opioid tolerance, which increases their risk of overdose to rates even higher than when they entered detox. Residential treatment does not typically include medications for OUD during the treatment program. 

“Previous studies have shown that FDA-approved medications for opioid use disorder work by reducing opioid use, keeping people in treatment and, for methadone and buprenorphine, decreasing mortality,” said Alexander Walley, MD, MPH, a physician in general internal medicine and researcher with the Grayken Center for Addiction, both at Boston Medical Center. “For this study, we looked specifically at mortality after discharge from detox based on further treatment with medication for opioid use disorder and residential treatment.” 

In collaboration with the Massachusetts Department of Public Health, BMC researchers examined individually-linked data sets for persons age 18 and older in Massachusetts with health insurance, focusing on individuals who had gone through detox between January 2012 and December 2014. This timeframe allowed for 12 months of observation prior to and following the first recorded detox. The researchers investigated the 12-month all-cause and opioid-related mortality rates after detox for individuals discharged who: did not get any treatment for OUD; received medication for OUD following discharge; received residential treatment (discontinuing medication); or received residential treatment and medication for OUD.

The data showed that the all-cause mortality rate for those who received no treatment after detox was high, at 2 percent per year, with overdose being the primary cause. Fifteen percent of individuals received medication for OUD in the month after detox, and for those who remained in treatment, their all-cause mortality decreased by 66 percent compared to those who received no treatment. Seventeen percent of individuals received residential treatment, and their all-cause mortality was reduced by 37 percent compared to those who received no treatment. Only three percent of those in the study received both medication for OUD and residential treatment, and their all-cause mortality was reduced by 89 percent compared to those who received no treatment. 

“Opioid use disorder is a chronic condition best addressed with ongoing treatment,” said Walley, also an associate professor of medicine at Boston University School of Medicine. “The data from our study shows that medication and residential treatment for opioid use disorder reduce the risk of overdose and death, but these treatments need to continue in order to be effective.” 

Of the individuals included in this study, less than half received further treatment after detox, and continued engagement in care in both inpatient and outpatient settings was not typically sustained. The authors note that the combination of medication and residential treatment may be especially effective for those at highest risk.

“It is important to consider the initiation of medication during detox, as well as the expansion of the care system that would enable better collaboration between residential treatment centers and MOUD programs to improve access to medication and increase the number of people remaining in treatment,” added Walley. 

This study was funded in part by the National Institutes of Health’s National Center for Advancing Translational Sciences (grant award #1UL1TR001430).

Credit: Boston Medical Center

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Surgical patients receiving the opioid Tramadol have a somewhat higher risk of prolonged use than those receiving other common opioids, new Mayo Clinic research finds. However, the Drug Enforcement Administration (DEA) classifies tramadol as a Schedule IV controlled substance, meaning it’s considered to have a lower risk of addiction and abuse than Schedule II opioids, such as oxycodone and hydrocodone. The study was published in The BMJ.

“This data will force us to reevaluate our postsurgical prescribing guidelines,” says lead author Cornelius Thiels, D.O., a general surgery resident in Mayo Clinic School of Graduate Medical Education. “And while tramadol may still be an acceptable option for some patients, our data suggests we should be as cautious with tramadol as we are with other short-acting opioids.”

The Mayo team of physicians and researchers used the OptumLabs Data Warehouse to examine the records of 444,764 patients who underwent 20 common surgeries across the U.S. between Jan. 1, 2009, and June 30, 2018. The OptumLabs Data Warehouse contains de-identified administrative claims data, including medical claims and eligibility information from a large national U.S. health insurance plan, as well as electronic health record data from a nationwide network of provider groups.

The team found that 357,884 filled a prescription for opioids after surgery.

Among them:

• 7% had at least one refill 90-180 days after surgery, which was defined by the team as additional use.
• 1% refilled their prescription 180-270 days after surgery, which was defined as persistent use.
• 0.5% had 10 or more prescription fills or 120 or more days’ supply, which was defined as long-term use.

And, the team discovered, patients in all three categories were more likely to have received a prescription for tramadol.

“We found that people who got tramadol were just as likely as people who got hydrocodone or oxycodone to continue using opioids past the point where their surgery pain would have been expected to be resolved,” says senior author Molly Jeffery, Ph.D., the scientific director of research for the Mayo Clinic Division of Emergency Medicine. “This doesn’t tie to the idea that tramadol is less habit forming than other opioids.”

Schedule II drugs are the highest classified drugs in the U.S. that are deemed to have an accepted medical use. Tramadol, sold under brand names such as ConZip and Ultram, was approved by the Food and Drug Administration in 1995 but wasn’t legally a controlled substance until 2014.

The researchers add that these findings suggest additional dialogue is needed on the drug’s treatment by the DEA.

“Given that tramadol is not as tightly regulated as other short-acting opioids, these findings warrant attention,” Dr. Thiels says.

The researchers found that tramadol use has been increasing over the study period, and at 4%, it was the third most prescribed opioid in this study. Hydrocodone was prescribed the most at 51% followed by oxycodone at 38%.

Previous Mayo Clinic research has led to evidence-based opioid prescribing guidelines developed for specific surgery types and individual patient factors. In some cases, these guidelines have significantly reduced the amount of opioids prescribed while still managing patient pain. The team also has shown that a large portion of patients may not need an opioid prescription after surgery.

Study co-authors are Elizabeth Habermann, Ph.D., and W. Michael Hooten, M.D. — both of Mayo Clinic.

This research was funded by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. Center research focuses on transforming clinical practice. Researchers seek to discover new ways to improve health; translate those discoveries into evidence-based, actionable treatments, processes and procedures; and apply this new knowledge to improve patient care.

Source: Mayo Clinic