The Pendulum Has Swung Too Far

Treating Pain in Primary Care

Linda Brookes, MSc

Disclosures

February 22, 2019

In This Article

Prescription Opioids Are Not the Main Culprit

No one disputes the role that prescription opioids played early on in the opioid epidemic, which the US government has called "the worst drug crisis in history."[8] The odds of dying from an accidental opioid overdose are greater than dying in a motor vehicle crash.[9] The increase in opioid prescription rates in the early 1990s was accelerated by both increased use and the launch of the American Pain Society's Fifth Vital Sign campaign.[10,11]

The now-notorious launch and marketing of OxyContin (Purdue Pharma) alone accounted for over 7 million prescriptions in 2001.[12,13] Opioid prescriptions peaked in 2010, a year in which enough prescriptions were dispensed to supply 4 out of every 5 US citizens.[14] Although not a surprise in hindsight, that increase was paralleled by a dramatic increase in deaths due to opioid overdose,[15] particularly associated with higher doses.[16]

The overall national opioid prescribing rate has been declining since 2012. That year, just under one fifth of the US population were prescribed one or more opioid prescriptions annually; fewer than 1 out of 10 was for a high dosage.[17]

Death rates involving prescription opioids have remained high, albeit stable, since 2016, even though the rate of overdose deaths involving all opioids has been on the rise since 2012. Although these deaths were initially due to heroin, since 2013 most deaths have been due to illicitly manufactured fentanyl and fentanyl analogues. Prescription opioids now account for about one third (36%) of all opioid overdose deaths.[18] That percentage is projected to continue to decline.[19]

Are Guidelines Up To the Task?

Guidelines for management of chronic pain issued around 10 years ago recommended opioids as the drugs of choice.[20,21] Reid, who participated in the panel that authored the American Geriatrics Society guidelines for chronic pain management in older adults told Medscape that "we knew that nonsteroidal anti-inflammatory drugs (NSAIDs) had not only significant adverse cardiovascular but also nephrotoxic effects. Because pain is difficult to treat in an 80- or 90-year-old with multiple clinical conditions, opioids appeared to be a more appropriate choice for patients with severe pain that could not be managed by other means. I would say in hindsight, our understanding of the potential harms of this strategy was not what it should have been. A evidence base demonstrating harm associated with prescription opioid use emerged after release of the guideline."

The idea of 'don't prescribe an opioid, don't prescribe drugs, just prescribe nondrug modalities' is fine until it comes face to face with the reality that in many communities, it is simply not viable.

Concerns about increases in opioid prescribing and abuse led the Centers for Disease Control and Prevention (CDC) to issue a guideline in 2016 on use of opioid medications for adults with chronic noncancer pain. Although the publicly released draft was generally supported by most US health organizations,[21] the final version raised concerns.

Canada did not adopt the CDC guideline because of several "important limitations"[22] said Jason Busse, DC, PhD, associate professor in the Department of Anesthesia Research, McMaster University, Hamilton, Ontario, Canada, and lead author of the Canadian guideline published the following year. "As far as we could tell, the CDC panel included individuals who were on record as being fairly critical of opioids for chronic noncancer pain," Busse said.

He also criticized some of the guideline's recommendations. "One was to prescribe opioids only if the benefits are anticipated to exceed the harms. Who is not doing that?" he asked rhetorically. "What clinicians need is specific guidance on the circumstances where the harms will exceed the benefits," he declared.

In a commentary in the New England Journal of Medicine , Thomas Frieden, MD, MPH, then CDC director, and Debra Houry, MD, MPH, director of the CDC's National Center for Injury Prevention and Control, opined that nearly all prescription opioids were "no less addictive than heroin" and that "for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits."

The American Medical Association (AMA) and others[23,24] pointed out that nonpharmacologic therapies, such as physical therapy, exercise, and cognitive behavioral therapy (CBT), which the CDC recommended as preferred over opioids, are not widely available or universally covered by insurance plans or Medicare. "There aren't many people in the United States who are trained to deliver these kinds of therapies," Reid noted. "So the idea of 'don't prescribe an opioid, don't prescribe drugs, just prescribe nondrug modalities' is fine until it comes face to face with the reality that in many communities, it is simply not viable."

The CDC recommendation that had the greatest repercussions was that physicians should avoid prescribing opioid dosages above 90 morphine milligram equivalents (MME) per day. The guideline did not specify whether the limitation was intended to apply only to new prescriptions or also to legacy patients, Busse pointed out. "Because of that, my sense is it has been applied to both types of patients," he said.

The AMA was concerned that insurers and other payers might use the recommendation to deny or impose new hurdles to coverage of any dose exceeding 90 MME/day, and that pharmacies would be under pressure to deny prescriptions that exceed that threshold. This is in effect what happened, as federal and state governments made reducing opioid prescribing a major priority and incorporated the CDC's recommendations, which the CDC itself acknowledged were based on low-quality evidence, into law. The effects on people living with chronic pain have been termed "catastrophic."[25]

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