Depending on your practice, you may have been hoping for or fearing the day when all turn and ask, “Why are ever-increasing doses of opioids being used to treat chronic non-cancer pain?”
With the first national guidelines on opioid prescribing, that day is upon us, and many are scrambling to provide an evidence-based response to our patients, professional societies, and government regulatory services. The issue here is not simply whether or not there is sufficient evidence that long-term opioid use for non-cancer pain improves pain and quality of life. In fact, there is little if any evidence of benefit past one to three months of use, and a growing burden of morbidity and mortality.
How do we proceed in the face of daily news briefs intended to improve the safety of opioid-based pain care, when we see a patient today who has been taking over 300 oral morphine equivalents daily for the past three years?
From 2000-2014, the number of deaths related to opioids in the United States consistently increased, and its toll now exceeds that of deaths from automobile accidents. These numbers don’t reflect additional opioid-induced side effects and morbidity – increased sensitivity to pain (hyperalgesia), depression, anxiety, hormone imbalance, and the acquisition of blood-borne pathogens from intravenous use. We suspect that millions are struggling with these issues.
Where do patients obtain the majority of opioid analgesics that are thought to drive these catastrophic figures? They are overwhelmingly prescription pain–killers, often shared by a friend or relative for free, and often prescribed originally for postoperative pain. Of the opioid-related deaths in 2014, 63 percent were from prescribed synthetic and semi-synthetic opioids. The USA constitutes only 4.6 percent of the world’s population, but consumes 80 percent of the world’s opioids and 99 percent of the world’s hydrocodone.
It tells you something about the prevalence of opioid use when a Super Bowl commercial advertises a drug (naloxegol) for managing an opioid side effect. Which is more disturbing – the fact that there is enough money invested in this product to purchase a $5 million, 30-second slot to air during Super Bowl 50, or that there are so many people affected by opioid-induced constipation?
Is the answer to limit the access to opioids? Although such recommendations are interwoven into recently released CDC guidelines, we must come to the realization that many daily opioid users will turn to other sources – friends, family, or “the street”. In anticipation of this, we should not cease therapy abruptly on our patients. Creating a plan for tapering rather than revoking opioid prescriptions should be first and foremost.
In response to these and other cross-cutting developments, we hope that pain physicians will seize this as an opportunity to lead. It should be recognized that primary care providers shoulder much of the burden and responsibility to make difficult choices around opioid prescribing. Pain physicians can work alongside primary care providers, and through education and consultation provide their expertise in non-opioid strategies.
Our leadership will be essential, as all physicians will now need to embrace the spirit of the recent CDC guidelines encompassing three critical components:
- Determining when to initiate or continue opioids for chronic pain (choices of non-opioid or non-pharmacologic therapy, treatment goals, risks and benefits discussed);
- Planning opioid selection, dosage, duration, follow-up and discontinuation;
- Continuous assessment of risk and addressing harms of opioid use.
There are several ways pain physicians can lead in educating their patients, medical students, residents, fellows, and referring physicians. It can begin with dispelling certain myths that have developed around opioid-prescribing habits.
Myth #1: There is no ceiling effect with opioids.
Despite extremely high doses of opioids in individuals, there appears not to be a proportionate increase in benefit. With the increasing number of opioid-tolerant patients coming in for surgery, it is a daily occurrence to see a patient taking over 1,000 oral morphine equivalents continuing to have severe pain with continued escalation in dosing. While the ceiling of opioids is high compared to other common analgesics, there is a ceiling.
Myth #2: Opioids are always the most effective treatment for pain.
Although opioids may be effective for some people in certain situations, they are actually less effective for control of dynamic pain that occurs with movement. According to the Oxford Pain Group League table of analgesic efficiency for acute pain, cyclooxygenase (COX) inhibitors such as diclofenac and celecoxib have a lower “number needed to treat” (NNT) than opioids in these circumstances.
Myth #3: You only have to worry about the acute effects of opioids.
In practice, chronic opioid effects actually include withdrawal, tolerance, dependence, impairment while driving or operating machinery, diversion, misuse, abuse, addiction, hypogonadism (specifically low testosterone in men, and amenorrhea/dysmenorrhea in women), hyperalgesia, immunosuppression, and increases in feeding and growth hormone that can lead to weight gain.
Acknowledging that opioids may continue to represent a component of a patient’s analgesic plan, several approaches can help minimize risk and better ensure that opioids are having their desired effect. These include:
- Establishing opioid patient-provider agreements
- Continual discussion of opioid risks and benefits
- Avoidance of concurrent benzodiazepines (the sister epidemic with 7,945 deaths in 2014)
- Use of pre-clinic risk assessment tools and/or assessment by a pain psychologist
- Participation in a prescription drug monitoring program (PDMP) or CURES 2.0, that includes urine drug screening
- Providing each patient and family or support network with access to an opioid reversal agent such as naloxone
- Encouraging functional restoration and physical therapy
- Encouraging complementary and integrative approaches including acupuncture and traditional Chinese medicine
- Providing information on how to secure opioids and restrict opioid access at home.
Many patients do not know that they should return or appropriately dispose of opioids if they are not using them. We as physicians must do a better job of educating around this topic.
So, finally, where did the opioid epidemic come from? To put it succinctly, from the following:
- A society disproportionately fearful of suffering
- Patient satisfaction surveys
- Reckless prescribing
- The fragmenting American patient-doctor relationship
- Lack of formal education on pain and opioids
- Lack of formal research on the risks and benefits of chronic opioid use
- Institutional policies mandating measurement of pain as the “5th vital sign”
- Misuse of the WHO Cancer Pain Ladder
- Pharmaceutical direct-to-consumer marketing and direct-to-prescriber marketing.
In the background is the fact that a large percentage of our population is afflicted with chronic painful conditions – by some estimates affecting over 100 million Americans.
How we can best manage pain in our cultural context is a great challenge that reaches across society and medicine. As physician anesthesiologists in California, we all must begin to accept more responsibility, embrace this challenge, and continue to lead.