Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________ one of health care’s least valued commodities. This is especially the case in emergency department (ED) settings, where evaluation is often based on patient volume and not on time spent with individual patients. As such, it is faster and pays better to diag- nose pain and prescribe an opioid than to diagnose and treat addiction [65].
Emergency Department Admissions The legacy Drug Abuse Warning Network (DAWN) was established in 1972 by the Drug Enforcement Administration to track and publish data collected from participating states on ED visits resulting from substance misuse or abuse, adverse reactions, drug- related suicide attempts, and substance abuse treat- ment [70]. By its final year in 2011, legacy DAWN had collected data from metropolitan areas in 37 states, with complete coverage in 13 states. Although their total figures did not capture all 50 states, the population rates were representative and able to be extrapolated to the United States as a whole [71]. In 2011, the overall admission rate for misuse or abuse of opioid analgesics (excluding adverse reac- tions) was 134.8 per 100,000, an increase of 153% compared with 2004. In the 13 states involved in the legacy DAWN network, the top four opioid analgesics involved in drug-related ED visits for 2011 were various formulations of oxycodone (175,229), hydrocodone (97,183), methadone (75,693), and morphine (38,416). Between 2004 and 2011, ED admissions increased 74% for methadone, 220% for oxycodone, 96% for hydrocodone, and 144% for morphine. Importantly, there was no meaningful change in ED admission rates involving opioid anal- gesics between 2009 and 2011. If this is also borne out by subsequent data, it strongly suggests a plateau in the misuse and abuse rates of these agents [71]. As of 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) re-established DAWN and will retain the important aspects of legacy DAWN. In comparison to legacy DAWN, the re-established DAWN functions as a smaller-scale sentinel surveillance system, or an early-warning system. The new DAWN will focus on detecting “outbreaks” (i.e., sudden increases in ED visits for specific drugs), identifying new and novel psychoac- tive substances, monitoring the magnitude of the health effects from substance use (as reflected in ED visits), and documenting the geographic, temporal, and demographic distribution of the problems to inform planning and policy at the local, state, and national levels [72].
Increasing Population Rates of Chronic Pain Any discussion of the rising rates of opioid analgesic prescribing should also acknowledge the increasing prevalence of chronic pain in the United States, with data showing increasing rates over the past several decades that are projected to continue in the future. Musculoskeletal conditions are the most common type of chronic pain, with back pain the most common type of chronic musculoskeletal pain [66]. Increases in low back pain prevalence and associated disability have been quantified in several studies. For example, an investigation of low back pain rates over a 40-year period found increases in prevalence from 8.1% in 1956–1958 to 17.8% in 1994–1995 in men, and 9.1% to 18.2% in women [67]. A comparison of back pain prevalence in North Carolina between 1992 and 2006 found an increase in chronic, impairing low back pain, from 3.9% in 1992 to 10.2% in 2006, and an 11.6% annual increase in healthcare utilization and disability [68]. Data from the National Center for Health Statistics estimate that in 2021 20.9% (51.6 million) of adults in the United States had chronic pain and 6.9% (17.1 million) had high-impact chronic pain (defined as pain that limits life or work activities on most days or every day in the past six months), with higher prevalences of both types of pain reported among women, older adults, previously but not currently employed adults, adults living in poverty, adults with public health insurance, and rural residents [69].
OPIOID ANALGESIC- RELATED MORBIDITY
There are a number of ways that the larger picture of opioid analgesic-related morbidity may be examined. Because the effects of opioid analgesic misuse can manifest in many ways in a variety of settings, it is important to examine data from different sources in order to get an accurate picture of opioid-related morbidity in the United States.
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MDMS1526
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