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Prescription Opioid Use Among U.S. Adults: Our Brave New World

In this issue, Han and colleagues present striking results from an analysis of the 2015 National Survey on Drug Use and Health (1). They estimate that 38% of U.S. adults used prescription opioids in the prior year. Among these 92 million persons, 13% reported prescription opioid misuse, and 2% reported a prescription opioid use disorder. Who is most at risk for problems related to opioid medications? In more than 20 years practicing primary care in safety-net health settings, I have come to think of the patients at highest risk as my patientsthose with lower levels of education and income and higher rates of unemployment and uninsurance, our society's most vulnerable members. The authors suggest that the way out of this opioid crisis is through improved access to evidence-based pain management and a decrease in excessive prescribing. These are the types of interventions that we can implement in our medical practices. Although I fully endorse these approaches, I believe that a much broader upstream approach is necessary. I am reminded of Steven Schroeder's 2007 Shattuck Lecture on social determinants of health and their contribution to premature death (2). If 90% of the contributors to poor health lie outside the health care system, the solutions will likely need to focus on policies that aim to alleviate social contributors to poor health. In his Hillbilly Elegy: A Memoir of a Family and Culture in Crisis (3), Vance eloquently tells a story about despair and loss of hope that lies behind Han and colleagues' data. Vance writes about stagnant class mobility and joblessness in Appalachia, an epicenter of the national opioid epidemic. Han and colleagues unearth this despair in their data. Respondents with a major depressive disorder and those with suicidal ideation had a higher prevalence of prescription opioid misuse and use disorders than those without these conditions. The fact that uninsured persons were twice as likely as those with insurance to report prescription opioid misuse and also had higher rates of use disorders augments the urgency of expanding insurance coverage. With insurance, persons suffering from pain could seek medical care rather than relying on opioids prescribed for others or purchased illegally. Insurance would also enable persons with depression to seek appropriate care rather than self-medicating symptoms with prescription opioids. Insurance also facilitates treatment of substance use disorders. However, expanding insurance coverage is necessary but not sufficient to address substance use disorders (4) and improve health outcomes (5, 6). In fact, Han and colleagues' data show that Medicaid beneficiaries and those with private insurance are also at risk for prescription opioid use disorders. Safety-net hospitals and clinics, which disproportionately care for uninsured and underinsured populations, will have difficulty increasing access to evidence-based pain management in response to the opioid problem. Safety-net settings often have lowor negativeprofit margins, with fewer resources and services available (7), including specialty care (8) that focuses on pain management. Moreover, many specialty providers do not accept patients with Medicaid and other forms of public coverage. Although opioid use disproportionately affects socially disadvantaged populations, the opioid epidemic has touched all strata of U.S. society. It has not spared privately insured persons and those with higher incomes and education levels. Likewise, our broken system of primary care contributes to the problem. Talk to any busy full-time primary care physician, and it becomes evident that writing an opioid prescription is much easier than exploring other options for addressing chronic pain in the course of a 15-minute visit. The same stressful work conditions likely also make it difficult for primary care providers to appropriately monitor patients who take opioids in the long term with urine drug tests and pill counts to assess for opioid diversion or other substance use. A potential solution to the problem of the overburdened primary care physician is to distribute some of the work to other members of the health care team. Indeed, we have found that using a nurse care manager with a registry increased receipt of guideline-concordant care (urine drug testing and patientprovider agreements) among patients receiving long-term opioid therapy. The intervention also resulted in reductions in opioid doses at a large urban safety-net hospital and 3 community health centers (9). Future iterations of this work might enlist nurses to perform routine pain assessments and deliver evidence-based interventions rather than opioid prescriptions for pain. In response to California's termination of Medicaid benefits for the state's 270000 medically indigent adults, Nicole Lurie, past president of the Society of General Internal Medicine, said, Don't get angry, get data. Whenever I pass the corner of Massachusetts Avenue and Albany Streetan area variously known as methadone mile and an open-air drug marketon my way to clinic at Boston Medical Center, I see the human face of the opioid epidemic, and I get angry. Han and colleagues have given us much-needed data to move from anger to action. The action will need to come from clinicians as well as those outside the medical profession who can help to address the underlying issues of poverty, uninsurance, and hopelessness that feed our current epidemic of opioid misuse.