Editor's Memo: Prescription Opioid Abuse is Declining
Good news! Although the abuse and diversion of prescription opioid medications increased between 2002 and 2010, both appear to have plateaued or decreased between 2011 and 2013, according to a recent report in The New England Journal of Medicine1 This most welcome development might help neutralize the negative press and pejorative attacks that recently have been directed at the pain management field.
To evaluate trends of abuse and diversion, the authors used 5 programs from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System to evaluate the diversion and abuse of all products and formulations of 6 prescription opioid analgesics: oxycodone, hydrocodone, hydromorphone, fentanyl, morphine, and tramadol. From 2002 to 2013, the programs gathered data from drug-diversion investigators, poison centers, substance-abuse treatment centers, and college students.
In general, RADARS System programs reported large increases in the rates of opioid diversion and abuse from 2002 to 2010, but then the rates flattened or decreased from 2011 through 2013. “The rate of opioid-related deaths rose and fell in a similar pattern. Reported nonmedical use did not change significantly among college students,” noted the authors.
The escalation of abuse and misuse of prescription opioid medications during the past 2 decades culminated in 16,651 opioid-related deaths in 2010. In response, hundreds of federal, state, and local interventions and regulations have been implemented since 2010. A growing number of states have implemented Prescription Monitoring Programs (PMP), manufacturers have developed Risk Evaluation and Management Strategies (REMS) programs, and many other groups have created public awareness measures about pain management and prescription drugs. In addition, the Drug Enforcement Agency is working with local health departments and law enforcement to establish a safe disposal program for unused medications.
Role of Abuse-Deterrent Alternatives
Coinciding with a decline in opioid diversion has been the introduction of abuse-deterrent alternatives. The goal of these new formulations of extended-release (ER) opioids with abuse-deterrent technology is to deter prescription opioid abuse while maintaining appropriate access to care for pain patients. A study from Brigham and Women’s Hospital has shown that introduction of these alternatives might help identify legitimate pain patients from potential abusers.2 In their study, the authors analyzed medical claims data following the introduction of 2 reformulated ER opioids with abuse-deterrent technology. A total of 31% to 50% of patients avoided switching to reformulated ER opioids. “Rates of diagnosed opioid abuse were higher among these patients compared to patients who transitioned to the reformulated ER opioids,” reported the authors. “Some patients switched to other ER/long acting (LA) opioids without abuse-deterrent technology or discontinued ER/LA opioid treatment when their existing ER treatment was reformulated. Rates of opioid abuse were higher among patients who switched to other ER/LA opioids or discontinued ER/LA opioid treatment, suggesting that abusers may seek more easily abusable alternatives such as prescription opioids without abuse-deterrent technology.”
While it appears that these measures are beginning to have the intended effect, there are some unintended and harmful consequences. For example, restrictions on supplies and the refusal of some pharmacies to fill opioid prescriptions for legitimate pain patients in some parts of the country is inhumane, unnecessary, and is causing patients, families, and practitioners to lose faith in their government’s ability to be fair and caring. The recent RADARS report also showed something that should not be a surprise—a rise in the use of heroin, with its attendant deaths. This further illustrates that opioid abusers are not legitimate, bona fide pain patients, but addicts who need to be in methadone maintenance or buprenorphine-naloxone (Suboxone) programs.
Of no surprise to me is that the RADARS data indicates that opioid prescribing, per capita, has been declining since 2010. Lost in all the media outburst is that pain practitioners are learning how to better prescribe and administer opioids. Today we have some effective treatment alternatives, which help minimize the average daily opioid dose requirements for most pain patients. The new abuse-resistant opioids are winners only if insurance companies will pay for them.
A major point that I want to make here is that the opioid diversion and overdose problems are primarily caused by opioid misuse and abuse of pills and capsules. For someone looking to abuse these medications, they can be sniffed, smoked, injected, or dissolved in alcohol. Hence the risk for overdose goes up. As a result, this editorial calls for pain practitioners, whenever possible, to use tablets or capsules that are abuse resistant or non-oral forms of opioids. Although opioid patches, liquid, and transmucosal opioids can be manipulated and abused, they have not been a significant part of the abuse and diversion problem.
The new formulations of transmucosal immediate-release fentanyl (TIRF), which are approved for the treatment of breakthrough pain, include oral lozenge, buccal tablet, buccal film, sublingual tablet, nasal spray, and sublingual spray formulations; each has practical considerations that vary with the product and route of administration.3 All have the common advantage of rapid entry into the circulation, avoiding liver and intestinal first-pass metabolism and allowing a rapid onset of action that rivals intravenous injections.
Let all of us do what we can to prevent diversion and abuse but also speak loudly about the overreach and unintended, negative consequences of some of the overzealous control measures. One last point, since the decline in abuse and diversion of prescription opioids is good news, isn’t it curious that the media hasn’t mentioned it.
Also In This Issue
We have a number of great educational articles this month. First, Mary Lynn McPherson, PharmD, and her colleagues provide an article on methadone, an inexpensive, long-acting opioid that appears to work very well in patients with neuropathic pain conditions. Many physicians are not comfortable prescribing methadone, but with training, this agent is a very effective therapy. Dr. McPherson is one of the leading experts on the use of methadone in the country, and this review is a great educational piece that outlines the proper uses and caveats of methadone treatment for chronic pain.