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5 Articles in this Series
Introduction
A Worldwide Take on Opioid Prescribing and Access
Evolution of the Neuropathic State and Evidence-Based Treatment
Incidence and Causes of Persistent Chronic Pain After Major Surgeries
Notable Industry Surveys
Putting a Stop to Guideline Warfare: Lower Back Pain

A Worldwide Take on Opioid Prescribing and Access

With presentations by Richard Rosenquist, MD, James Rathmell, MD, Jose de Andres, MD, and Amany E. Ayad, MD

Four physicians from around the world gathered on one stage to provide a global perspective on the opioid epidemic as part of a 2018 World Congress on Regional Anesthesia and Pain Medicine panel.

Changes in Usage, Changes in Expectation

Richard Rosenquist, MD, an anesthesiologist at the Cleveland Clinic, opened the discussion by addressing the shift in opioid usage among Americans over the past few decades.1 Historically, he said, heroin users started with heroin; now, in about 80% of cases, people start with prescription medications. A whole generation that never would have considered taking heroin have now sought cheaper or other sources when prescription opioid wore off, without realizing they had developed a physical dependence or an addiction.

A patient with a marked acute injury who is prescribed opioids has a likelihood of developing chronic pain. By avoiding the opioids from the beginning, that patient may avoid such a destination. Dr. Rosenquist pointed to the science coming out of several key research labs, including the recent SPACE randomized trial led by Krebs, which demonstrated pain intensity reductions in the studied non-opioid group compared to the opioid group. This and other emerging data marks a growing battle between analgesia and hyperalgesia. Fortunately, interaction with toll-like receptors and TLR-dependent central immune signaling, as well as glial inflammation, are starting to be better understood, noted Dr. Rosenquist. But communication among opioid prescribers and patients also needs to be better understood.

In its simplest form, he explained, pain is often a normal part of life and healing, and this is just one change in expectation needed to shift the opioid epidemic paradigm. Going forward, pain control needs to involve active engagement on the part of the patient and prescribers need to carry out patient education, with a few crucial points, among others, to be emphasized:

  • not every visit gets a pill
  • mental health is important
  • 100% pain relief is not likely
  • pain treatment does not equal opioid use.

This approach, backed by existing resources and knowledge, needs to apply not just to pain specialists but also to primary care physicians, emergency department personnel, and so forth, he urged.

Clinicians also need to be cautious of drug combinations (eg, opioids and benzodiazepines, sedatives) and increase their patient follow-up. Paying attention to requests for refills and other patient behavior is crucial as well, he said. Overall, Dr. Rosenquist concluded that excessive amounts of opioids have been prescribed for too long, noting physicians are not undertreating pain, but rather, are not treating it successfully in many situations. Long-term success will take time involving a concerted multifront effort, especially as it has become so easy to obtain synthetic and dangerous forms of opioids.

 

Have the Guidelines Gotten Us Anywhere?

James Rathmell, MD, of Brigham and Women’s Health Care, discussed current published guidelines on opioids,2 starting with IOM’s 2011 Blueprint for Relieving Pain in America and ending with the August 2017 CDC guidelines on chronic pain, and their effect on prescribing patterns.  

The latter guidelines focused on a lack of long-term evidence for safe opioid use, especially at a dose higher than 90 MME/ day. The CDC urged, among other practices, the use of immediate- over extended- release formulations, slowed pace, tapering when needed, risk factor considerations, and limited medication for acute pain (no more than what is needed)—this last recommendation has received the most attention, said Dr. Rathmell. But have these guidelines made a difference? “We have seen a leveling off of opioid prescriptions between 2011 and 2017,” he stated, but now there is an increase in heroin and synthetic fentanyl-related deaths, he noted, referring to the latest data.

One challenge is that there is still not a lot of evidence in the literature about how many opioids anesthesiologists and post-surgical prescribers need to use for common surgical procedures, such as a cesarean or even a tooth extraction. Brigham’s comprehensive opioid response and education program (BCORE) has come up with some responses to these questions. With three task forces put into play (prescribing, addiction, education), the BCORE plan was rolled out within the Brigham community, complemented by ongoing education and coordination. After about 18 months, the number of opioids prescribed across all Brigham physician types declined by approximately 30%, Dr. Rathmell told the World Congress audience. In the state of Massachusetts, during this same time period, prescription opioid overdoses leveled off but infused heroin overdoses skyrocketed.

The impact begs the question: Have efforts to reduce prescribed opioids caused another major problem? How do we balance effective chronic pain treatment with this mania over prescription opioid overdose, asked Dr. Rathmell? We need to co-manage patients over time in collaboration with our substance abuse experts, he advised. The impact of federal guidelines is not yet clear - more time is needed, but meanwhile, general practitioners are less willing to prescribe opioids and training for new practitioners on opioids is virtually nill. Where this leaves the pain community is still up in the air.

 

Does Europe Have it Right?

Jose de Andres, MD, and Amany E. Ayad, MD, provided international perspectives to the discussion panel. A representative of the European Society of Regional Anesthesia and Pain Therapy, Dr. Andres is a professor of anesthesia at Valencia University Medical School and director of the Pain Management Center at Valencia University General Hospital in Spain.3 What is often not mentioned in global opioid discussions, he said, is that Europeans can use other countries’ healthcare under their health insurance card scheme. Data, therefore, may be skewed.

He described how European practitioners apply similar approaches to pain management, including close long-term follow-up, alternative methods, and the core goal of patient functionality and quality of life. But, he noted, European regulations and reimbursement models may work in favor of reduced opioid prescribing across the continent.

For instance, some of the rules enforced across different European countries include: opioids may not be prescribed for longer than 30 days; records must be kept for several years; individuals cannot drive legally while on a stable course of strong opioids; prescription form validity is governed; and reimbursements for non-cancer opioid prescriptions are limited.

In addition, pointed out Dr. Andres, rather than restricting opioids, which many American prescribers are now doing, European physicians are instead enforcing good clinical behaviors and follow-up from the beginning. Routine monitoring includes documentation of the patient’s pain and function, progress made, adverse effects, and adherence to the prescribed therapy. The full patient profile is assessed and regular urine drug screens are performed for high-risk individuals.

While this clinical approach does not seem far off from that of US pain practitioners, Dr. Andres emphasized that the stricter rules and regulations in Europe may indeed be the reason behind Europe’s better opioid situation.

He did note that pain is a leading therapeutic spend and growth category in Europe, topped only by oncology and diabetes. Morphine and codeine have high-predicted growth opportunities for the European pharmaceutical market, despite a marked gap in current opioid consumption between the European and US regions, with the US consumption rate significantly higher (200% more in 2008; that gap is slowly shrinking). Despite the growth, only about 5% of prescribed opioids in Europe are considered to be “strong” opioids, he said, and that statistic has largely remained consistent over the past decade.

 

The Developing World Dynamic

Dr. Ayad, a professor of anesthesiology at Cairo University representing Africa’s Society of Regional Anesthesia, addressed opioid utilization in developing countries as part of the panel.4 She said the political and economic nature of Egypt and Africa at large clearly play into aspects of pain presented to their medical community. As many as 25.5 million adults suffer from intractable pain with virtually zero relief, not to mention children living with pain and those individuals who are so isolated that data does not exist for them. Six developed counties, including the US, consume 95% of the world’s prescribed opioids alone.

As a result, she said there are difficulties in studying opioid use and even epidemiology in developing countries like those in Africa. Significant differences in homogenousity add to this challenge. Infrastructure and regulations also factor in. In Egypt, she noted, some opioids are manufactured more cheaply stateside than global resources and, therefore, statistics regarding consumption and access may not be included in World Health Organization reports. As another example of how prescription opioids are limited in the developing world, she listed a few policies pertinent to Armenia: five panelists must examine a patient at home to approve a single morphine prescription; multiple stamps of approval are needed for an opioid prescription; and non-cancer patients are ineligible for receiving opioids.

In addition, there is stigma throughout Africa that opioids are associated with end-of-life care, as well as concerns around addiction; these cultural and social perceptions are only bolstered by negative reports of the US epidemic. Finally, she stated, medical training is severely limited.

Dr. Ayad argued that education among clinicians as well as patients, increased access to globally manufactured opioids, and lightened regulatory measures are required to begin adequately treating patients living with chronic pain in developing Africa. In essence, while Egypt and Cairo University/Hospital in particular may have a healthcare advantage over some other countries in Africa, the opioid situation between the region in general and that of the US and even Europe is quite stark, with more global understanding and strategy needed.

Simply put, she said, “We don’t have the time and resources to repeat your mistakes.” At the same time, Dr. Ayad made a point of reassuring practitioners from developing countries in the audience that there is hope - significant technological and sociopolitical advances in healthcare are being made in Egypt and throughout the region.

 

Sources

1. Rosenquist R. Paradigm Shift: Chronic Opioid Management in the USA. Presented at the World Congress on Regional Anesthesia and Pain Medicine, April 19-21, New York City

2. Rathmell J. Have Published Guidelines Influenced Opioid Prescribing Patterns and Improved Outcomes? Presented at the World Congress on Regional Anesthesia and Pain Medicine, April 19-21, New York City

3. Andres J. Past, Present, and Future State of Opioids in Europe. Presented at the World Congress on Regional Anesthesia and Pain Medicine, April 19-21, New York City

4. Ayad A. Opioid Utilization in Developing Countries: Working Towards a Blanked Approach. Presented at the World Congress on Regional Anesthesia and Pain Medicine, April 19-21, New York City

 

Next summary: Evolution of the Neuropathic State and Evidence-Based Treatment
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