It’s no secret that the Opioid Crisis is here to stay. In the United States, over 115 people die from opioid overdose, including prescription opioids, heroin, and synthetic opiates like fentanyl. The Center for Disease Control and Prevention (CDC) estimates that the total cost of healthcare, loss of productivity, addiction treatment and criminal justice involvement totals to $78.5 billion a year in the US alone. Worldwide, it is estimated that 27 million people suffer from opioid use disorders but less than 10% of them who need treatment are receiving it. With opioid use and death from opiate use on the rise, how did we get here?
In later half of the 1990s, pharmaceutical companies had prescription opioid pain relievers on the market but there was concern for addiction. The companies reassured prescribers, pharmacists, and the medical community as a whole that patients would not become addicted to prescription opioid pain relievers. This led to an increase of opioid prescriptions, and widespread abuse of these medications before it was clear to the medical community that these were highly addictive. As addiction rose so did the rate of opioid overdose, by 2015 33,000 American had died from opioid overdose.
In present day, doctors are more reluctant to prescribe opioids and their costs on the black market have increased. This drives abusers to street drugs such as heroin. In order to keep up with demand, dealers and suppliers cut their heroin with high potency opioids acquired from overseas like fentanyl. Fentanyl is a synthetic opioid used in patients with severe pain needing long term pain management, and it is 50 to 100 times more potent than morphine. Most fentanyl-related harm come from illegally made fentanyl mixed into heroin, sometimes without the user’s knowledge.
The opioid epidemic has become a public health crisis with devastating consequences far beyond the users. There is a rising incidence of neonatal abstinence syndrome (infants born who suffer from opioid withdrawals), plus an increase in intravenous drug use increases the spread of HIV and hepatitis C. In order to combat this, some US states are offering safe needle programs and increasing overdose prevention intervention. One of these agents is known as naloxone. Naloxone is an inexpensive medication that can completely reverse the effects of opioid overdose and prevent death from opioid overdose. New opioid prescribing and dispensing programs have been started, along with continued education on safe opioid prescribing practices for prescribers.
The World Health Organization (WHO) recommends tackling the opioid crisis with a variety of treatment options, including psychological support, opioid maintenance treatments such as methadone and buprenorphine and supported detoxification and treatment with reversal agents such as naloxone. The WHO also supports countries where these treatment programs don’t already exist. The United States, and the world has acknowledged the opioid crisis, but we are a long way from solving it.
Featuring Dr. Carpenter from UNC ESOP
Dr. Carpenter is an assistant professor in the Division of Pharmaceutical Outcomes and Policy. She is currently involved in diverse research projects such as developing online training module for community pharmacist (suicide prevention and naloxone overdose) and for health professionals to learn how to make decision on pediatric opioid usage. Also, she has a project that collaborates with Monash and UCL where she is developing an app that monitors medical non-adherence of the patient.
Unlike other professors, she received phD in public health and focused on medical adherence during her graduate school. After, she received a postdoctoral award in NIH she got recruited as a research assistant professor in University of North Carolina Eshelman School of Pharmacy. She is currently teaching Social & Behavioral Aspects of Pharmaceutical Use course, which addresses health behavioral series for medication use. In this course, students get to learn about diverse factors that influence medication adherence and several theories that would improve medication adherence of the patient. She is also co-directing the RASP (Research and Scholarship in Pharmacy) project for pharmacy students in UNC Eshelman School of Pharmacy.
Lastly we asked Dr. Carpenter for any comments to students who are interested in the field she is currently in..
“Take advantage of PharmAlliance opportunity! I am currently working with pharmD students from UCL as part of their research rotation, so be aware that you can be involved in research projects from different schools. If you are interested in working in research, take advantage of PharmAlliance and reach out to the researchers in different campuses.”
"Fight the Fakes" is a campaign that aims to raise awareness about substandard medications, which is a big threat to public and patient safety. University College of London students and faculty have been prominent in the Fight the Fakes campaign, with students and faculty members representing at local and global meetings to raise awareness and advocacy for this very important cause.
The following editorial was posted on April 2018 on the Lancet Respiratory Medicine. Click here to view the full article.
The illegal market in fake medicines is a growing threat and is harming patients the world over—this was the headline of Fight the Fakes, an event at University College London (UCL) on March 16, 2018, which aimed to provoke action on the urgent global issue of falsified and substandard medicines.
Considering the fact media these days are constantly badgering society about the health impacts of obesity and our ever-increasing sedentary lifestyles, it should not have come as a shock that a high proportion of the top drugs used by Australians are all cardiovascular related. Combine that with the problematic over-prescribing of common antibiotics and the ever rising prevalence of type two diabetes, and the top 10 medications shouldn’t really have been too hard to guess either.
When looking at the most commonly used drugs within Australia, there were two ways to go about it; Either purely by the number of prescriptions filled for that particular medication each year, or more specifically the number of individuals per 1000 people who take a standardised dose of this medication each day.
Looking directly at the number of prescriptions, it is clear that as a nation we are battling with hypercholesterolemia in high numbers. With over ten million prescriptions filled for both atorvastatin and rosuvastatin, they each claim the gold and silver medals respectively at the top of our list. Not only this, but when comparing these drugs with lists from the previous year, yet again they were highly featured with atorvastatin remaining as number one and rosuvastatin claiming third, showing a trend which can be traced back for a number of years.
To fill out the top three by prescription numbers from July 2016-June 2017, esomeprazole took the bronze with around six and a half million scripts filled within the twelve month period. Whilst this was a drop from second place during the previous year, the notably high positions of both itself and its fellow proton-pump inhibitor pantoprazole (fourth place, up from fifth the previous year) shows that conditions such as GERD and gastric ulcers are becoming more and more prevalent amongst the community. Whether this can be associated with an increase in the self-use of OTC anti-inflammatories, or an increase in fatty or spicy foods within the diets of Australians may be up for speculation, however the numbers speak for themselves.
Rounding out the top ten by prescription count are commonly prescribed antibiotics such as amoxicillin and cephalexin, as well as medications for blood pressure and diabetes. However, some observations that can be made from this list are the high number of antibiotic scripts being filled within Australia. With the total count of the top three exceeding fifteen million, it is clear that a high proportion of Australians have undergone courses of antibiotics under the recommendation of doctors, especially considering the population of Australia currently sits at around 24 million people.
On the other hand, when analysing the medications used by the Australian population, the best measure to gain some perspective on the number of people taking drugs for chronic conditions is to look at the number of individuals per 1000 people who take a standard daily of dose of a specific medication. And when looking at the list, the prevalence of cardiovascular conditions such as hypertension and hypercholesterolemia are huge, with eight of the top ten medications coming under the umbrella of cardiovascular medications.
And once again taking the top two spots, and not surprisingly after our previous list, were HMG-CoA reductase inhibitors atorvastatin and rosuvastatin. Not only are these drugs considered highly effective at lowering patient’s cholesterol levels, but they are also very easily accessed due to their relative low price point. Not only that, but their positive effects are easily monitored by doctors through a simple blood test.
Rounding out the top three within Australia was perindopril, an ACE inhibitor commonly prescribed for the lowering of blood pressure, as well as for patients with established coronary heart disease in order to lower the risk of a myocardial infarction. And while it is a first line therapy choice for patients with hypertension, it also needs to be monitored carefully, particularly amongst patients taking diuretics or NSAIDs. This is due to what we call the ‘triple whammy effect’ which actually reduces the effectiveness of the ACE inhibitor in controlling a patient’s blood pressure. However, like the statins, perindopril is also an easy to access medication with relatively low prices.
Now when compiling this list there are some medications which were not counted, presumably as they are not covered by the Pharmaceutical Benefits Scheme, and in fact cheaper to purchase over the counter without a script or even simply more convenient. So, whilst there are a large number of patients regularly taking high dose paracetamol in order to control pain, and there are large numbers of salbutamol inhalers being sold daily within pharmacies around the country in order to control asthma symptoms, they are not shown as part of these statistics.
When looking at the drugs that are regularly used by Australians it is clear that our cardiovascular health is deteriorating as a nation. If a prediction was to be made about future lists and medication use for the years to come, we could probably say that these figures are unlikely to change a lot as well. But if one thing is for sure, it is that with the ever increasing demand of medication usage in Australia, the need for helpful and involved pharmacists is as high as ever.
Figures and statistics obtained from The Commonwealth of Australia’s Department of Health and published on NPS Medicine Wise. Links to the top drug tables from both 2016-17 and 2015-16 can be found below.
Top Drugs in Australia 2016-2017-https://www.nps.org.au/australian-prescriber/articles/top-10-drugs-2016-17
Top Drugs in Australia 2015-2016-https://www.nps.org.au/australian-prescriber/articles/top-10-drugs-2015-16