US Opioid Epidemic Fueled by Prescribing Practices

Pam Harrison

September 28, 2015

The United States is facing the worst "man-made epidemic" of opioid abuse in the history of modern medicine, and it is the direct result of poor research and outdated teaching practices, according to a leading pain expert.

"There's been over 200,000 deaths from prescription opioids and many more hundreds of thousands of overdose admissions, and millions are addicted or dependent on prescription opioids, and while some patients don't meet the classic definition of opioid use disorder, as many as 30% of patients who are sitting across from you in your office have opioid use disorder or are severely dependent," Gary Franklin, MD, MPH, vice president of Physicians for Responsible Opioid Prescribing, said during a Webinar sponsored by the Centers for Disease Control and Prevention's Clinician Outreach and Communication Activity (COCA).

"So this is an extremely serious epidemic, and while I know that taking care of these patients is not an easy thing to do, we need to reduce overdose deaths and admissions, and we have ways to reverse trends which we all need to embrace."

The most important step toward reversing the epidemic of prescription opioid abuse is to stop prescribing opioids for the wrong indications.

Recent reports have consistently concluded that there are insufficient data on the long-term effectiveness of prescription opioids to support their use in the treatment of chronic pain, but there is clear evidence of a dose-dependent risk for serious harms.

The biggest triggers to the initiation and perpetuation of prescription opioid abuse comes from their use for the treatment of nonspecific musculoskeletal disorders, especially chronic low back pain, headaches, and disorders such as fibromyalgia.

Although there is no proven benefit for their use in these disorders, "people with these indications are on chronic opioids, and they have become disabled, and they are spilling over into social security and disability systems," Dr Franklin said.

In recognition of this problem, the American Academy of Neurology and a number of states, including Washington, have produced guidelines that advise that in general, opioids should not be routinely used for the treatment of musculoskeletal conditions, headache, or fibromyalgia.

"Not only is there no evidence to support their use in these conditions, there is quite a bit of evidence against doing so, and these are probably the most routine patients we have who are on chronic opioids and who have become dependent and addicted to them in our country," Dr Franklin said.

Indeed, in a 2008 study conducted by Dr Franklin and colleagues (Spine. 2008;33:199-204), results showed that 14% of workers who sustained a low back injury were disabled at 1 year and that receiving opioids for at least 7 days at a cumulative dose of 150 mg morphine equivalent dose (MED) doubled the risk of being on disability 1 year later, after adjusting for baseline reported pain, function, and injury severity.

Dosing Guidance

The issue of the MED and the risk for an overdose event, either hospitalization or death, is also extremely important in community efforts to reduce the risk for opioid-induced harm.

Recent evidence suggests that there is a dramatic increase in death when opioids are administered at a dose of 100 mg MED ― "but the risk of overdose is also two- to fivefold higher when that same opioid MED runs between 50 and 99 mg MED," Dr Franklin said.

"So you need to be paying a lot more attention to lower doses of opioids and never go over 100 mg MED."

This is particularly important for patients who are receiving a combination of an opioid and either a benzodiazepine or another sedative-hypnotic or muscle relaxants, all of which can dramatically add to the risk for opioid harm, even at lower doses of opioids, he added.

Dr Franklin also cautioned that the intermittent use of opioids does not spare patients from overdose and that in doses lower than 100 mg MED, many patients enrolled in Washington State's Medicaid program have been admitted for opioid overdose even when they were not using opioids on a long-term basis.

Comprehensive guidelines from Washington State on prescribing opioids make it very clear that physicians must proceed with caution when initiating opioid therapy to improve function and pain in patients with chronic pain or when transitioning to the long-term use of opioids.

Before initiating treatment with any opioid, patients should be screened for current or past substance abuse as well as depression.

Clinically Meaningful Improvement

"When you are tracking pain and function, you also have to make sure there is clinically meaningful improvement in both pain and function," said Dr Franklin.

In Washington State, a clinically meaningful improvement in pain and function means at least a 30% improvement in both.

Physicians also need to track pain and function at every visit so that they can better judge how well the opioid may be working — or not.

Sleep disturbances are common in patients with chronic pain, and physicians need to help patients with various measures to improve sleep hygiene or prescribe a tricyclic antidepressant, which will help with underlying depression as well sleep disturbances, he added.

There are also many nonpharmacologic alternatives to long-term opioid use that are strongly supported by evidence.

Graded exercise is well established as a good treatment modality for chronic pain, as are cognitive-behavioral therapy (CBT), mindfulness-based stress reduction techniques, and various forms of meditation and yoga.

If patients who are currently receiving opioids are scheduled for an elective operation, they should resume their preoperative dose of opioids 6 weeks after surgery.

If they are not receiving opioids at the time of the procedure, patients should be off all opioids within 6 weeks.

And if patients are not improving on opioid therapy, "the ongoing risk from continued treatment outweighs the benefit," Dr Franklin said.

"And opioids in these patients should be tapered to zero."

The new guidelines indicate that when tapering opioids, the dose should be reduced by 10% a week, with or without accompanying CBT, inpatient detoxification, or treatment in a pain clinic.

"These patients are losing their lives in our system, and we need to do everything possible to reverse this epidemic and saves lives," Dr Franklin said.

"And I am glad to say our efforts are paying off, as we have seen a 30% sustained decline in death from overdose in Washington State and a dramatic decline in the proportion of injured workers on chronic opioids as well."

A MED calculator is available online.

COCA Webinar. Posted September 24, 2015.

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