Deadly opioid overdose epidemic overshadowed by COVID-19

As if the deadly pandemic wasn’t bad enough, California continues to fight a battle against the opioid overdose epidemic.

A record 3,200 Californians lost their lives to opioids in 2019—well before the stress and disruption caused by COVID-19 caused overdose deaths to spike to new highs nationwide. By May 2020, powerful synthetic opioids such as fentanyl caused California’s 12-month all-drug overdose death rate to spike nearly 27%, significantly faster than the national average. In San Francisco alone, three times as many people lost their lives due to drug overdose than from COVID-19.

This crisis didn’t just come out of nowhere. It snowballed over time, fueled by an overprescription of opioid-based painkillers.

One major underlying contributor is the over‑prescription of opioid-based painkillers both during and after surgery.

Studies have found that patients who receive opioids after short-stay surgeries face a 44% increased risk for long-term opioid use than those who didn’t receive the potentially addictive drugs. As a surgeon, I’ve seen firsthand the effects persistent pain can have on a person, and I understand how hard it can be for many people to stop opioids once they’ve started.

That is why I strongly believe change is necessary to ensure that these powerful painkillers are prescribed only when appropriate and that all patients can confidently access non-opioid alternatives to manage pain.

While opioid addiction has many causes, one major underlying contributor is the over‑prescription of opioid-based painkillers both during and after surgery. According to an analysis on the impact of overprescribing in America, roughly 3 million people each year become frequent opioid users following a surgical procedure. Additional research shows that patients receiving an opioid prescription after a hospital short-stay or outpatient surgery are 44 percent more likely to become long-term opioid users afterwards.

Through my work as an ophthalmologist, I’ve seen how one of the greatest risks of opioid exposure can occur both during and after cataract surgery. Although this is generally a low-risk procedure – with thousands performed in the United States each day — as many as 35 percent of cataract surgery patients experience moderate-to-severe post-operative pain, many of whom received an opioid such as fentanyl during surgery.

Furthermore, an examination of the risk of long-term opioid use found that cataract surgery patients who received an opioid prescription post-surgery were 1.6 times more likely to use opioids long-term compared with patients who were not prescribed an opioid. Because nearly 4 million cataract procedures are performed each year, it only takes a small percentage of patients becoming addicted to represent a substantial number of new opioid users.

Given the severity of our nation’s opioid crisis, this failure to adequately cover alternatives to opioids is mindboggling.

Fortunately, the medical community has begun to take this issue seriously in recent years. In addition to the development of new prescriber guidelines meant to ensure opioids are prescribed in a manner that reduces the risk of addiction, many providers have turned to alternative pain management techniques that are often just as effective.

For cataract surgery patients — particularly those with small pupils – innovative and FDA-approved therapies such as Omidria (phenylephrine and ketorolac intraocular solution, 1%/0.3%) have been demonstrated to be effective at maintaining pupil size by preventing intraoperative miosis, reducing postoperative ocular pain, decreasing the need for postoperative drops and protecting against sight-threatening complications.

Studies have also found that the drug could effectively reduce the need for fentanyl during surgery by nearly 80 percent and decrease the amount of postoperative opioids prescribed by 56 percent.

Unfortunately, the Medicare program does little to support practices that use non-addictive alternatives. In fact, current reimbursement policy ensures that it’s more economical for practices to prescribe patients opioids — which are often covered by patients’ Medicare Part D prescription drug plans — than a non-opioid treatment.

Given the severity of our nation’s opioid crisis, this failure to adequately cover alternatives to opioids is mindboggling.

COVID-19 and its social ramifications have accelerated our local and national problem of opioid addiction.

Thankfully, a growing number of leaders in Congress have recognized the problem with this perverse incentive structure and have introduced legislation to fix it.

he Non-Opioids Prevent Addiction in the Nation (NOPAIN) Act would help reduce the current disparity and expand patient choice for non-opioid alternatives. Importantly, the NOPAIN Act does not restrict the appropriate use of opioids for patients who need them. Instead, this bipartisan legislation requires that Medicare provide separate reimbursement for non-opioid treatments in hospital outpatient departments and ambulatory surgery centers — the same policies that exist for many private insurers, the VA, and even Medi-Cal.

This relatively small change would help to correct the disincentives and enable physicians to prescribe non-opioid pain management therapies when appropriate, thereby reducing the overall risk of patients becoming exposed to and addicted to opioids. Last Congress, the NOPAIN Act was cosponsored by California’s own Reps. Ami Bera, Harley Rouda, Josh Harder, Luis Correa, and Zoe Lofgren. Now that the bill has been reintroduced in the Senate, I urge Speaker Nancy Pelosi and the rest of our state’s congressional delegation in the House to support this common sense solution.

COVID-19 and its social ramifications have accelerated our local and national problem of opioid addiction. It’s time to pass the NOPAIN Act, which rightly aims to give providers more flexibility to provide Medicare beneficiaries – a population at increased risk – with effective and non-addictive pain management therapies following surgery.

It is my hope that passage of this commonsense legislation will allow California to see a rapid decline in the number of opioid addictions, deaths, and suffering that plague our communities.
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Editor’s Note: Dr. Randal Pham is an award-winning, board-certified eye surgeon in San Jose with a special interest in the prevention and treatment of world blindness.