The U.S. Opioid Epidemic is one of the greatest public health challenges that we will address in the 21st century. In 2015, 12.5 million people aged 12 or older misused prescription drugs designed for the relief of pain. However, some 10% of individuals with a substance use disorder received specialized treatment in 2015.
What factors forged such a great distance between the disease state and the treatment plan? Historically, our lay population has been fundamentally unequipped to address substance use disorders as disease states. Rather, we have regarded substance use disorders as chronic, irreversible bouts of moral weakness that our justice system is best suited to correct. In doing so, has our health care system neglected an incredibly nuanced, overwhelmingly human diseased population? We cover more in this article and invite your questions and feedback at the end of the page.
What do current opioid misuse statistics say?
Current statistics on prescription opioid misuse in the United States, in part, suggest that ineffective patient-clinician relationships may contribute to opioid misuse. Results from the 2015 National Survey on Drug Use and Health (NSDUH) were made recently available by SAMHSA. This report yielded significant insights into the source of prescription opioids among all past year misusers.
Among all people aged 12 or older in 2015 who reported misusing prescription opioids in the past year, 36.4% of respondents indicated that they most recently obtained drugs for the relief of pain through a prescription or health care provider, and these respondents typically received prescription opioids through one doctor (34.0%).
Additionally, the 2015 NSDUH surveyed the source where pain relievers were obtained for most recent misuse among individuals who meet clinical diagnostic criteria for pain reliever use disorder (as outlined by the Diagnostic and Statistical Manual of Mental Disorders – IV). Intriguingly, the most common source for past year misusers with a pain reliever use disorder was through prescription or health care providers (43.7%).
New regulations and legislation are paving the way
In recent years, the United States has embraced the Opioid Epidemic, and unique legislation has been designed to place tighter regulation on the access to prescribed opioids. For example, New Jersey Governor Chris Christie recently signed legislation to restrict initial opioid prescriptions to a five-day supply and mandate that state-regulated health insurers cover inpatient and outpatient treatment for drug addiction.
Additionally, I previously communicated progress on the implementation and adoption of Prescription Drug Monitoring Programs, which empower prescribers and dispensers with prompt access to patients’ controlled substance prescription histories, providing improved avenues to early interventions for at-risk, abuse-prone populations. These implementations represent progress in oversight of opioid therapy. However, improving prescriber-patient relationships is a critical step to both optimize guidelines for prescribing opioids as well as ensure patient compliance to opioid therapies.
Improving treatment outcomes with Rx guidelines
In an effort to reduce the number of individuals who misuse prescription opioid drugs, the Center for Disease Control (CDC) developed the CDC Guidelines for Prescribing Opioids for Chronic Pain. The goal of this publication is to improve communication between clinicians and patients about the risk-benefit relationship of opioid therapy. In this publication, the CDC outlines recommendations for prescribing opioids for chronic pain outside of active cancer, palliative, and end-of-life care. Here, I will summarize the most salient recommendations as they relate to the patient-clinician relationship and discuss how these guidelines can improve treatment outcomes.
“Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.”
SUGGESTION #1: Nonpharmacological therapies for pain.
The CDC advises that primary care providers should avoid drug therapy if it is unneeded. Thus, nonpharmacological intervention is preferred for the treatment of pain. Nonpharmacological therapies are vast and include:
- physical therapy for sports-related injuries
- psychotherapeutic strategies such as Cognitive Behavioral Therapy for the treatment of mood and/or related disorders
…and related treatment plans.
These opioid treatment options provide the greatest benefits relative to risks.
SUGGESTION #2: Nonopioid pharmacotherapies for pain management.
If drug therapy is needed for pain management, the CDC recommends a nonopioid pharmacologic therapy. Potential nonopioid pharmacotherapies include:
- acetaminophen (i.e. Tylenol)
- non-steroidal anti-inflammatory drugs (i.e. Advil)
…and related drugs.
Again, nonopioid therapies mitigate risk as the nonopioid pharmacotherapies listed are relatively unassociated with substance use disorders.
SUGGESTION #3: Opioid therapies in combination with nonopioid pharmacotherapies.
When opioid therapies are needed for chronic pain, the CDC recommends that they are administered in combination with nonpharmacologic therapy and nonopioid pharmacotherapies to reduce pain, improve function, and provide both the greatest benefits and least risk to patients.
Setting realistic pain management goals
“Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.”
In short, predictive factors of long-term opioid therapy benefits versus risks are largely unknown. Thus, the CDC recommends that clinicians consider plans to discontinue opioid therapy in the event that it is unsuccessful. When opioids are prescribed for chronic pain, the patient-clinician relationship should be rooted in a set of treatment goals that should reflect the patient’s specific ailment.
Establishing treatment plans with clear goals will inform treatment outcomes that may inform both when opioids are no longer needed as well as instances at which the risks of opioid therapy outweigh benefits. In line with these strategies, opioid therapies are ineffective to improve both pain and function, clinicians and patients should consider strategies to discontinue opioid use in favor of nonpharmacologic therapies and nonopioid pharmacotherapies.
Are you aware of opioid pain treatment risks and realistic expectations?
“Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.”
Transparency between the patient and clinician is critical to mitigate risks of opioid therapy. The CDC recommends consistent communication between patients and clinicians throughout opioid therapy in order to establish realistic potential benefits and harms.
Because the benefits and risks of long-term opioid therapies are uncertain, it is important that clinicians explicitly communicate side effects and adverse effects such as the development of opioid use disorder.
Identify at-risk patients using PDMPs
“Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.”
I discussed in a previous article the utility of the Prescription Drug Monitoring Program (PDMP), a set of state-specific databases that store information on controlled prescription drugs by dispensing prescribers. By referencing PDMPs in their states, clinicians can identify patients who have received opioids from multiple prescribers or receive highly total daily opioid dosages.
Encouraging clinicians to reference PDMPs may mitigate patient risk by identifying individuals who are most susceptible to opioid-related harms such as misuse or overdose. Alternatively, identifying patients with unusually high prescription opioid turnover, i.e., multiple controlled substance prescriptions written by different clinicians, may indicate instances where individuals are sharing, selling, or not taking opioids.
Opioid misuse and prevention questions
Want to learn more or have any questions regarding opioid painkiller prescription guidelines and use? Please post them in the designated section at the end of the page. We try to respond personally and promptly to all legitimate enquiries. In case we don’t know the answer to your question we will gladly refer you to professionals who can help.