HJNO Jul/Aug 2022

DRUG ADDICTION 16 JUL / AUG 2022 I  HEALTHCARE JOURNAL OF NEW ORLEANS   soared during the COVID pandemic due to job losses and isolation, causing high rates of depression and limiting our usual sup- port networks. A CDC report released in October 2021 showed a 56% increase from March 2020 to March 2021. 13 The rise of fentanyl has greatly increased the overdose death rates, given its potency and wide use. It’s cheap and easy to make, so distributors of illicit drugs use it to cut more expensive substances to lower their bottom line. New Orleans Coroner Dwight McKenna stated earlier this year in a press release, “Because of fentanyl, using street drugs in this day and age is like playing Rus- sian roulette with your life.”The statistics on fentanyl-related deaths are staggering. In the jurisdiction of the New Orleans Coro- ner alone, 94% of overdose death toxicol- ogy reports were positive for fentanyl in 2020 versus 78% in 2021. This is in addition to other positive drug tests such as cocaine and amphetamines. 14 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 the patients, after under- going surgeries, were being prescribed excessive opioids by their doctors and sur- geons to treat postoperative pain. One of the changes to improve this practice was to emphasize the use of acetaminophen, NSAIDs, and an extremely limited number of tablets and at lower MME’s (morphine milligrams equivalent) — in other words, from prescribing opioids for a whole month down to a week. The multimodal approach to pain management using various other methods is proven to be extremely effective in controlling pain. NSAIDs, acetaminophen, regional anesthesia (e.g., nerve blocks), and local anesthetic delivery pumps are all via- ble alternatives, as well as Cognitive Behav- ioral 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 know how to dispose the unused opioids. 13 Once a patient starts to show signs of opi- oid use disorder, the most likely places for them to regain access are pain management clinics. Some of these patients do not really have an organic cause of pain, but they use any pain “excuse” to have access to pre- scribed opioids. This is known as malinger- ing and/or secondary gain. This is where the extremely strict policies of pain medicine clinics come to play: The patients need to be submitted to extremely strict vetting procedures, medical exams, questionnaires, radiographic imaging, pill counts, drug screenings, the signature of a “pain management contract,” etc. One important and life-saving measure was to make it mandatory for any opioid prescriber to also prescribe naloxone if the patient is on 50 MME’s or more (this varies by state). Clinics are now liable for malprac- tice if this is not done! On the same note, first responders and police have started carrying kits with nalox- one to use in case they encounter a patient suffering an overdose event. They use them like EpiPens are used when facing an ana- phylactic reaction. And once it is determined that the patient is the right candidate to receive opioids to treat moderate to severe pain, we, as pain medicine specialists, need to follow the pre- ventive measures to the T. Various prescription monitoring pro- grams in the different states of the coun- try help tremendously to keep track of the number of opioids prescribed, the dates received, dosages, and doctors who sign the prescriptions. In Louisiana, we have the PrescriptionMonitoring Program (PMP) housed under the Louisiana Board of Phar- macy. This is extremely helpful in detecting “doctor shopping”practices, comparing the different prescribing practices of doctors, and raising red flags when patients are on dangerous combinations like benzos, Soma, etc. Before COVID, we started to see a plateau in the rate of opioid overdose events thanks to the measures mentioned above to control the opioid epidemic. Unfortunately, isolation, depression, anx- iety, and lack of hope triggered the misuse and abuse of opioids again. On top of all that, the trending in the decline of availabil- ity of prescribed opioids due to improved vetting made patients turn toward heroin and drugs laced with fentanyl, an opioid 100 times more potent than morphine, making it a lethal drug that has claimed so many lives. 13 We have tried to understand how we are in this evil opioid epidemic. In these three pieces, we have tried to not just talk about it but to bring awareness and hope that with a very committed medical community, and with the help of the different institutions, we should be able to defeat this deadly enemy, the “Opioid Epidemic”! n REFERENCES 1.Gill,N.S.“UnderstandingtheSignificanceofPandora’s Box.”ThoughtCo,updatedJune 27,2019.https://www. thoughtco.com/what-was-pandoras-box-118577. 2. Ammer, C. The American Heritage Dictionary of Idioms, Second Edition. Houghton Mifflin Hardcourt, 2013. 3.Hesiod,“Works,and Days.”47ff. 4. Lipinski, J. “Justice for Danny: How a small town pharmacistcaughthisson’skiller.”Nola.com,TheTimes