EDITOR’S NOTE: This is the final installment in a two-part series that assesses the impact on America’s rural health population of the CDC’s guidelines for prescribing opioid painkillers.

Pharmaceutical research shows that 80 percent of opioid medications are for generic drugs, and while the CDC guidelines likely will continue to cut into sales and prescriptions of opioids (clinicians already have scaled back on prescribing because of addiction concerns, after all), that won’t change the fact that pharmaceutical companies continue to introduce new pain medications that are harder to abuse or don’t contain opioids. This industry will need to continue to have a finger on the pulse of developing need within the medicine marketplace.

Some solutions to this include:

  1. Prescription drug monitoring programs need to be continued. Currently they are in use in every state except Missouri, but the difficulty is that most physicians aren’t using them. Whether this is due to lack of program knowledge or that it’s too cumbersome and time-consuming isn’t clear, but what is clear is that clinicians must be central to the process.
  2. Controlling dependence can be achieved in part by rescheduling hydrocodone opioid products from the Class III to the Class II under the Drug Enforcement Administration (DEA) schedule, making it more difficult for pharmacists and clinicians to automatically refill prescriptions, and in many locations limit prescriptions to a 30-day supply.
  3. There must be reinforcement of strategies to reduce overdoses, including stronger warning labels, safer disposal methods to reduce diversion of drugs, and the development of opioids specifically designed to discourage abuse, such as pills that can’t be crushed and snorted.

Will these efforts actually yield results for rural populations? In the CDC director’s own words from a recent interview, “if you’re prescribing an opiate to a patient for the first time, that’s a momentous decision. That may change that patient’s life for the worse forever. So you’ve really got to think carefully before doing it.”

An additional CDC expert on prescription drug abuse in the U.S. noted that “people who take prescription painkillers can become addicted with just one prescription. Once addicted, it can be hard to stop.”

To that end, shouldn’t we finally be thinking differently in our overall approach to the epidemic? The old adage of doing the same thing reaping the same results often holds true, and more than just guidance is required.

We already know the 10 leading factors of why drug addiction is so prevalent in rural areas, ranging from dangerous work industries resulting in injuries to socioeconomic stressors to the cycles through which chronic diseases, including depression, often feed into higher addiction rates – and the fact that rural points often are key for drug traffickers. But what if we got down to the genetic level in addressing addiction?

Clinically speaking, a provider is supposed to determine whether there is a personal history and/or a family history of substance abuse. Family history offers a clue related to the genetic predisposition of addictions. Variants in genes such as ANKK1/DRD2 give insight into the risk associated with prescribing an opioid to a patient with a family history and these specific gene variants. Furthermore, care should be taken to determine whether a patient might effectively metabolize opioids through the Cyp2d6 pathway. Poor metabolizers place patients at risk for increased toxicity, and rapid metabolizers may often request larger dosages.   

Additionally, since the new CDC guidelines encourage providers to find alternatives to opioids, a patient’s personalized response should be taken into consideration. The CDC noted in the guidelines that “the prescriber should use the lowest possible effective dosage.” With that said, the lowest possible effective dosage for approximately 20 percent of the population who rapidly metabolize an opioid is different than a patient who is a slower metabolizer. Knowing that dosing should differ between individuals is critical. 

We have tried nearly everything else – so why don’t we try the genesis of life in looking at genes as a true solution for the drug epidemic?

Where there’s a will, there’s a way.

About the Author

Ali-Dinar, PhD,  is the chief operations officer at MedFirst Partners and a senior rural health expert at Healthcare Solutions Connections. She has more than 10 years of experience in rural health policy, legislation, strategy, and operations, having served on the National Rural Health Association’s national rural congress. Dr. Ali-Dinar is also an NRHA Rural Fellow.

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