| One-Minute Clinician

There’s More than One Opioid Epidemic

Despite what the media and regulatory agencies and politicians say about there being an opioid epidemic, it’s not a single entity as most people would want to believe. It makes it seem as if a single action is going to solve it when in actuality it’s more than one thing, and that requires different activities to help temper what’s happening. Technically, everything we’re talking about is an opioid. The real question is “Is it a prescription opioid that was obtained from a healthcare provider, and is that really what is fueling the opioid overdose fatality rate?” What is increasingly clear is that opioid overdose deaths are becoming more related to heroin-fentanyl, fentanyl, cocaine, and even fentanyl and marijuana. As a synthetic opioid, fentanyl can be manufactured anywhere in the world, and that’s exactly what’s happening. It comes into the country through the dark web, the US Postal Service, FedEx, UPS, or through people carrying it across the border. $800 of fentanyl has a street value of about $800,000. That’s an incredibly lucrative business model.

Heroin abusers, three quarters of the time, start off abusing prescription pain medications, and that gives regulators and legislators the opportunity to look to healthcare providers to solve the problem. But there are 2 crises that need to be separated, as opioid prescribing becomes more restrictive, so that providers don’t throw in the towel saying “If there’s all this pressure that’s going to fall on my shoulders for something that I’m not even responsible for, I’m going to just wash my hands of the whole thing.” The only people who suffer in that kind of situation are the patients. One thing that I think healthcare providers need to do in order to continue to minimize harms and stay in the game is to go beyond their relationship with the patient in terms of assessing risk-benefit ratio. There’s a new math that needs to be utilized, and that means the household and the community need to be factored into the risk-benefit ratio, and suicidal implications need to be factored in as well – because we’re not likely to be able to control the amount of illicit substances that come in to this country. Fentanyl is not going to go away, but healthcare providers have a responsibility to monitor patients to see if there is any illicit substance use, and they also have a responsibility to now look at what the potential risks are in the penumbra that surrounds the patient.

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