Addressing the Opioid Epidemic.

摘要: Afteralcohol intoxication,opioidsare themostcommoncause ofpoisoninginpatientspresentingtoNorthAmericanemergency departments.1Mostopioidsmisusedbypatientsoriginate from prescriptionmedication.Most patientswhooverdoseonprescription opioids are taking their medications differently thanprescribedorareusingopioidsprescribedtosomeoneelse. These2main typesofnonmedical opioiduse representamajor causeofmorbidityandmortality.Someindividualswhomisuse opioidsareseekingeuphoriceffects,butothershavedeveloped dependence through chronic opioid use and simply trying toavoidopioidwithdrawal.Opioid-relatedharmhasnowreached epidemic levels: emergency department visits for nonmedical useofprescriptionopioidsmorethandoubledfrom2004to2011, accountingforanestimated488 000visits in2011.1Deathshave more than tripled since 1999, with an estimated 16 235 deaths attributable to prescription in 2013.2,3 In this issueof JAMA, the studybyHanet al4 examined current scopeof theopioidepidemic theUnitedStates.Using datafromnearlyhalfamillionrespondentstotheannualNational SurveyonDrugUseandHealth(NSDUH), theauthors foundthat overalltrendsinself-reportednonmedicaluseofprescriptionopioidsdecreasedfrom5.4%to4.9%overan11-yearperiod, includingadecline innewusersofopioids, from1%in2003to0.6%in 2013.Althoughthisoverall findingofa reduction innonmedical useofprescriptionopioidsisencouraging,thestudyalsoreported increases theprevalenceofprescriptionopioidusedisorders (abuseandaddiction)and theprevalenceofopioidassociatedmortality,usingdatafromtheNationalVitalStatistics System’sMultipleCauseofDeathFiles.Theauthorsalsoreported increasedprevalenceof frequentopioiduse (>100days/year) highly frequent (>200 days/year), as well a greater prevalenceofprescriptionopioidusedisorders inpatientswith majordepressiveepisodes(MDEs)thaninpatientswithoutthem. The findings ofHan et al suggest thatmore patients experiencing inexorable progression initial use, or disorder. Another report issue of JAMA by Saloner Karthikeyanaddressedarelatedquestion:Dopatientswithnonmedical access treatment?5 Among individuals identifiedinNSDUHashavinganopioidusedisorder, utilization substance abuse treatment during sameperiodasHanetal (2004-2013).Adjustedratesof individualswith disorders receiving treatmentwere lowand essentiallyunchangedduringthereportingperiod(18.8%in20042008to19.7%in2009-2013).SalonerandKarthikeyanalsofound thatthenumberofsettingsvisitedfortreatment(ie, inpatientservices,outpatientclinics,physicians’offices) increased, from2.8 to3.3, includingreceiptoftreatmentinofficesettings(from25.1% to34.8%)whereuseofbuprenorphineismost likely.Theauthors cannot explain why so many apparently did not seek treatment, suchaswhether it isnot available,not affordable, notof interest.Furthermore, theoutcomesof treatmentcannot bemeasuredwiththesedata,butotherstudieshavereportedthat long-termeffectiveness ofmost such therapies ismodest.6 Karthikeyan also found that over time, survey respondents were older less likely have private health insurance. Despite Mental Health Parity Addiction Equity Act 2008,7 which mandated insurersoffermentalhealthandaddictionbenefits comparablewith medical-surgical benefits, increase opportunitieswasnot observed latter part studyperiod, after act was implemented. This suggests ability topaymost likelywasnot theprimary factor thedecision forgo but does clarify roles to, interest in, Prescribingofopioidanalgesics,particularlyforchronicpain, appears be amain themajority use. Basedonotherdataavailable theNSDUH,prescribersare,directlyor indirectly, sourceofmostmisusedopioids.8Anestimated53%ofnonmedicalusersreportedobtainingprescription opioidsfromafriendorrelative,81%ofwhomreceivedtheirdrug fromaphysician. It isunclearwhether theseprescriptionswere issuedfortherapeuticpurposesororiginatedfromunscrupulous prescribers (ie, “pillmills”); regardless, sourceofopioiduse andmisuse is often seemingly legitimate prescription. There little evidence long-term benefit therapy formost typesof chronicpain.9 remainsunclearwhy thispracticeofopioidprescribingcontinuesdespite recommendationstothecontrary.9,10Newopioidmedications,manyofthem withtamper-resistantformulations,continuetobemarketeddespite lackofevidencethat thesepreparationsreducetherisk ofaddiction.11More than10%ofpatientswho initiate withopioidswill likelyprogress tochronicuse,definedasongoingtreatmentformorethan3months.12Nearlyallpatientstreated withlong-termopioidtherapydeveloptoleranceanddependence tovaryingdegrees,about25%becomenonmedicalusers,and10% developfeaturessuggestiveofaddiction.13Thesearesoberingpercentagesinlightofthemillionsofpatientsprescribedthesedrugs everyyear.14Consequently,forthemanypatientswhoneedtreatment addictionor complicationsof substancemisuse, there areoftensignificantbarriers toobtainingcare.6Dependence,addiction, anddose escalation resulting tolerancemakediscontinuingopioidsdifficult.Manypatientsunderstandablyperceivetheyneedongoingopioidanalgesic therapybecause,when thedrugsarediscontinued,anunpleasantwithdrawalsyndrome withassociatedpainensues.Patientsquickly learnthat resumpRelated articles pages 1468 1515 Opinion