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PAINSCAN LITERATURE REVIEW
Issue 1, Volume 4
Addiction Medicine and Relapse Prevention

About the Authors

8 Articles in this Series
Introduction
The Krebs SPACE Trial
Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid and abuse
The influence of anxiety sensitivity on opioid use disorder treatment outcomes.
Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations
The Addiction Patient
What the SUPPORT Act Means for Providers
Inside the NCASA Report: Ending the Opioid Crisis
The role of opioid prescription in incident opioid abuse and dependence among individuals which chronic non-cancer pain

Introduction

The current state of opioid prescribing, addiction, and response in the United States - by Jennifer Schneider, MD, PhD 

The State of Opioid Affairs

One of the most commonly discussed public health issues in the US today is the opioid overdose deaths crisis and how to solve it. The “usual suspects” are clinicians who prescribe opioids, and the most commonly proposed solution is to decrease the number of opioid prescriptions.  One approach is regulatory: The CDC 2016 guidelines1 on prescribing opioids for chronic pain, aimed at primary care physicians, has been interpreted by many states as a requirement for all prescribers not to exceed between 60 and 120 mg morphine equivalents (MMEs) per day, depending on the state, with a major push to avoid going over 90 MMEs. Another strategy is research focused: academic, for-profit, and nonprofit organizations alike are conducting studies on the benefits (or lack thereof) of opioids in managing chronic pain, as well as on the risks at stake when they are prescribed. An increasing number of published studies have concluded that opioids offer minimal benefits while carrying high risks of abuse, diversion, or addiction, thus supporting the theory that the primary solution to the opioid crisis is to minimize prescribing.  

 

Addiction is not the Usual Outcome of Opioid Use

The major assumption behind both efforts is that prescribers are turning most of their chronic pain patients into addicts, resulting in a large number of patients at risk of opioid overdose deaths. In reality, however, “addiction occurs in only a small percentage of persons who are exposed to opioids – even among those with pre-existing vulnerabilities,” as stated by Nora Volkow, director of the National Institute on Drug Abuse (NIDA), part of the NIH.2 Multiple publications support this conclusion. In a review of 67 studies of addiction following opioid use, Fishbain, et al,3 reported a risk of 3.27%. A Cochrane review4 found a median incidence of 0.5% of de novo addiction, and a median prevalence of 4.5%. They concluded that, “opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence [ie, addiction or opioid use disorder].

Some of this confusion about risk of addiction results from the false belief that physical dependence, an expected consequence of chronic opioid use, is the same as addiction, currentlytermed Opioid Use Disorder (OUD). This author explains the difference in a recent paper.5  Another misunderstanding is that patients living with chronic pain are likely to develop a tolerance to the analgesic effect of opioids (and/or opioid-induced hyperalgesia) requiring an ever-increasing opioid dose. Prescribers typically do find that patients may need a dose increase, however, the reality is that there are reasons for this unrelated to tolerance, including the following:6

  • An opioid is initially prescribed in low dose in order to assess resulting nausea and sedation, and then increased if necessary for adequate analgesia.
  • When an effective dose is reached, the patient is then likely (as is hoped!) to increase his or her activity, with the result that another dose increase may be necessary in order to maintain the improved function.
  • When a dose becomes less effective after some months, depending on the source of pain, it may well be a consequence of disease progression.  (Read more on OIH). 

 

Other Approaches Are Needed

Since 2010, the quantity of prescribed opioids in the US has consistently decreased while the number of opioid overdose deaths has continued to increase.7  A recent analysis8 projected that the number of individuals using illicit opioids will likely increase by 61% between 2015 and 2025. Even more frightening is that, across all interventions tested which result in prevention of prescription opioid misuse alone, such as online prescription monitoring programs (PDMPs) and regulations about maximum doses, such are projected to decrease overdose deaths only by only 3.0 to 3.5%. Chen, et al, concluded that such interventions “may have a modest effect at best, on the number of opioid OD deaths in the near future. Additional interventions are urgently needed to change the course of the epidemic.”8

The simultaneous decrease in prescription opioids and increase in opioid overdose deaths is so counterintuitive that it clearly mandates consideration of other approaches to solve this crisis. A crucial part of the process is to understand which opioids are responsible for opioid deaths and which groups of people are taking these drugs. In reality, the statistics tend to combine several different groups, including:

  • those who purchase prescription drugs on the street to treat their anxiety, depression, PTSD, etc.
  • those who purchase prescription drugs on the street to experience a high and feed their addiction
  • those whose source was a bottle of prescription opioids found in a relative or friend’s home or who were given these drugs by a friend or relative
  • those who purchased illegal drugs, such as heroin or illegal fentanyl, for the same reasons as those listed above
  • those who accidentally took too many prescribed pills and overdosed
  •  those desperate individuals whose goal was to commit suicide.  

Separating overdoses from prescribed versus illegal drugs, the data show that the overwhelming source of increased overdose deaths is tied to illegal drugs. As prescribed drugs become less available, greater numbers of people are being driven to use more dangerous street drugs. Thus, solutions must involve other modalities while also providing access to opioids for those responsible patients whose function and quality of life is improved by these prescription medications.

 In addition, mental health must be considered as part of a patient-centered approach,10 which involves getting to know the patient better and addressing their underlying issues. Davis and Vanderah support this consideration in “A New Paradigm for Pain,”11 wherein they describe how developmental trauma, other traumatic experiences resulting in PTSD, and/or mental health disorders may cause changes in the nervous system, resulting in “psychological pain.”

It is well documented that opioids (especially immediate-release opioids) may be an effective psychotropic treatment for depression, anxiety, and PTSD.12 In a study of prescription opioid use among adults with mental health disorders, Davis, et al,13 found that, among 38.6 million Americans with mental health disorders, 18.7% used prescription opioids; this group received 51.4% (over half) the total opioid prescriptions distributed in the US each year. That is to say, an American with a mental health condition is four times more likely to be prescribed an opioid. It is further likely that many patients with psychological problems who are prescribed opioids for pain find that opioids also effectively treat their mental health conditions; thus, they may become reluctant to discontinue using such medications. These patients are not addicts but rather patients in need of behavioral health evaluation and treatment.

Framing the Discussion

Unfortunately, insurance companies are increasingly unwilling to pay for modalities other than medications and procedures. Joshua Sharfstein, former Principal Deputy Commissioner of the FDA, described the consequences of this approach just last year: “At a time when most insurers still do not provide adequate reimbursement for nonpharmaceutical approaches to pain or treatment for opioid use disorder [ie, addiction], overly restrictive prescribing policies risk pushing patients with pain or addiction to illicit drugs, a transition many have made.”14

Additional conversations are taking place around the use—and coverage—of naloxone to reverse opioid overdoses, and buprenorphine or methadone for maintenance of recovering opioid addicts. All are important tools.

...

In this PainScan on Addiction Medicine & Relapse Prevention, recently published papers will be reviewed in the coming months in an effort to help parse out the conclusions that advance the field from those that support preconceptions about the value and risks of opioid prescribing.

 

First Article:
The Krebs SPACE Trial
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