Map of life expectancy at birth from Global Education Project.

Tuesday, May 01, 2012

A tough problem . . .

. . . but there are solutions, or at least ways to improve the situation. A newly recognized consequence of the epidemic of prescription opioid abuse in the U.S. is a huge increase in the number of babies born addicted. Most, though not all (for reasons not well understood) of the babies born to women who are chronic opioid users will go through withdrawal (called Neonatal Abstinence Syndrome, NAS). Doctors give them opioid replacement, such as methadone, and wean them off gradually. They end up spending typically 16 days in the hospital at a cost of over $50,000, mostly paid for by Medicaid.

Stephen Patrick et al, in the linked report, find that the incidence of NAS increased from 1.2/1,000 births in 2000 to to 3.39/1,000, in other words almost triple. Investigators have yet to sort out the direct long-term consequences for these babies -- they often have problems later but their mothers, not surprisingly, are also disproportionately likely to smoke, drink alcohol, have poor nutrition and so on, and the babies go on to have a disadvantaged social environment. They have an increased risk of low weight birth, but whether that is a direct consequence of opioids is unknown. In any case, it's a humanitarian catastrophe and oh yeah, it costs a lot of money at a time when Medicaid programs everywhere are under strain.

I've discussed this opioid epidemic here before, but just a reminder, the driving force is misuse of prescription opioids. Some people who start with prescription drugs do end up using heroin because it's cheaper; but women tend not to like needles and so the epidemic prescription opioid abuse has meant a higher proportion of women get into trouble.

The difficulty is that there are completely legitimate uses for opioid analgesics, in fact they are a great boon to humanity and some people would suffer horribly, and unnecessarily, without them. But it's difficult for doctors to tell when somebody really needs them or just wants them because she or he is addicted, or intends to sell them. But here are some ways to improve the situation:

1. Shut down pill mills. Florida had a big problem with this, clinics that exist only to write scrips for dope. The governor refused to take action for a long time (maybe he had friends in the business), so Florida also has a disproportionate problem with NAS. These operations can be identified pretty readily, and there's no reason to tolerate them except that law enforcement doesn't make it a priority. We'd do a lot more good concentrating on them than on marijuana growing and trafficking.

2. Many states have registries for opioid prescriptions. They all should have them, and doctors should be trained (and perhaps required) to check them before writing a new scrip. That way they can find outif the person has recently filled opioid prescriptions elsewhere.

3. Offer treatment on demand. Stop locking up addicts in jail, which is very expensive and doesn't do any good. Have drug courts that divert them to treatment, and actually have the treatment available (which it often is not).

4. Create more comprehensive pain programs. There are alternatives to opioid treatment that will work well for many people, but there aren't enough physicians trained in comprehensive pain management.

5. Have universal health care, including dental care. Lots of people develop chronic pain because they have untreated conditions. They show up in Emergency Rooms and they need pain relief. ER docs can't tell the people with real dental pain (or whatever) from the fakers, so they write scrips indiscriminately. If they could just have the people seen right away by a dentist, that particular tactic would instantly become obsolete.

I can think of a few more but you get the idea. This is a problem that can be solved, or at least greatly ameliorated, if we take off the ideological blinders and approach it pragmatically. And that requires a government that responds compassionately to human needs.

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