COMMENTARY

Opioid Abuse: A Primary Care-Created Problem?

Kenneth W. Lin, MD, MPH

Disclosures

December 22, 2015

Editorial Collaboration

Medscape &

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Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University School of Medicine, and I blog at Common Sense Family Doctor.

Prescription opioid misuse and abuse is a deadly health problem that is becoming worse each year. The National Center for Health Statistics reported that in 2014, almost 19,000 people died of overdoses of legal opioid pain medications, such as oxycodone. This figure rose 16% from 2013 and accounted for nearly twice as many deaths as those from heroin overdoses.

News exposés about "pill mills," where corrupt physicians freely dispense huge quantities of controlled substances, have led some to mistakenly think that opioid overprescribing is mostly the fault of a small number of "bad apples." But the facts support a different view.

An analysis[1] of national Medicare prescribing patterns published in JAMA Internal Medicine found that the vast majority of opioid prescriptions are written by family physicians and general internists and are distributed equally across states and geographic regions. In other words, we have met the enemy, and he is us.

A multispecialty panel convened by the Centers for Disease Control and Prevention (CDC) recently posted for public comment a draft guideline on primary care prescribing of opioids for chronic noncancer pain. This guideline was based on a systematic review of the best available evidence on the benefits and harms. Unfortunately, few studies have measured the effects of chronic opioid use or compared them with other pain medications or alternative treatments. As a result, many of the guideline recommendations seem to be based mostly on common sense.

For example, establish realistic patient expectations ahead of time—only a small proportion of patients will achieve complete relief. Avoid prescribing opioids concurrently with benzodiazepines or other sedatives, if possible, to reduce the risk for an overdose. Follow up with a patient using opioids at least every 3 months, and discontinue therapy if he or she doesn't experience clinically meaningful improvements in pain or function that outweigh safety risks.

One point that I found surprising is that the CDC guideline recommends that primary care physicians preferentially prescribe immediate-release opioids rather than extended-release or long-acting formulations, at least at the start of therapy. I usually try to transition my patients with chronic pain to long-acting formulations as quickly as possible and reserve immediate-release opioids for breakthrough pain. However, the guideline found that long-acting formulations are associated with a higher risk for overdose among patients initiating opioid therapy. There is also no evidence that continuous use of scheduled long-acting opioids relieves pain better than intermittent dosing of short-acting opioids.

Another recommendation that I will consider incorporating into my practice is prescribing naloxone to patients at increased risk for opioid-related harms, such as patients with a history of overdose or a history of substance abuse, patients using benzodiazepines, and patients using more than 50 morphine milligram equivalents per day. The New York City Health Department provides a useful online calculator to convert doses of various opioids into morphine milligram equivalents. Although only community-based naloxone distribution has been shown to prevent opioid overdose deaths, writing prescriptions for naloxone rescue kits to high-risk patients in primary care settings feels no less appropriate than writing prescriptions for epinephrine autoinjectors for patients at high risk for anaphylactic reactions.

Finally, it is our responsibility as primary care physicians to do everything possible to steer patients with chronic pain toward opioid alternatives. Ultimately, though, some patients will still require opioid prescriptions—many patients have contraindications to nonsteroidal anti-inflammatory drugs, and not everyone responds to acetaminophen or acupuncture. To complement the work of our public health colleagues, we can use the CDC guideline to better inform patients about the life-threatening consequences of opioid misuse and work with them to minimize the risks.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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