The abuse of opiate analgesics has grown to the level of a national crisis. President Trump selected a committee on this crisis led by Governor Chris Christie of New Jersey. Governor Christie is well informed on the subject both from a the Executive standpoint and from a personal level as well. He understands what drug addiction can do to individuals and their families. This problem is so large and complex that it will require attacking the problem from a number of approaches. It is estimated that 100 Americans die each day from drug overdoses. At that level over 3000 lives are lost each year from a preventable cause. I believe that this crisis has been in the making since pain was classified as the “5th vital sign” in 1996. Since that time initial screening of patients includes questions pertaining to the presence of pain and the “level” of pain (usually on a scale of 1-10) the patient is experiencing. If pain is considered a “vital” sign then it was incumbent on providers to treat that abnormality. Patients who stated that they were having pain are often given a prescription for pain medication.
Opiates have long been a mainstay of pain management, blocking neurotransmitters at the receptors within the brain, spine and smooth muscle. Side effects of opiates relate to this mechanism and can include pupillary constriction, slowing of the gastrointestinal tract (constipation) and respiratory depression. The primary cause of death in overdose is profound respiratory depression and anoxia (lack of oxygen). There is an antidote in the form of naloxone (Narcan) that competes for the same receptors as opiate drugs. If given in acute overdoses it can be lifesaving. Paramedics and even police are often trained to deliver the medication to individuals who are unresponsive. Reversing the opiate drug can throw the patient into opiate withdrawal. Withdrawal symptoms can include restlessness, sweating and running of the eyes and nose. In some cases muscle spasm and seizures can ensue. Patients who withdraw at home or in a rehab program may have severe vomiting or diarrhea. This can be treated with fluid replacement and appropriate anti-spasmodic medications.
What is the solution for the opiate crisis. We need to attack this problem at multiple sites. Prescribers must be more judicious in the type and number of opiates given, pharmacists must alert prescribers when they suspect doctor shopping and families must be alert to behavioral changes in the individual. Safer ways of managing pain should be tried and insurers must be more willing to pay for drug rehabilitation programs and pain therapies. We must stop the senseless waste of human life while still addressing the 5th vital sign.