In the past decade, the field of pain management has come under tremendous pressure to re-evaluate best practices for prescribing opioid medications. First came a call to arms to recognize pain as the fifth vital sign and to tackle the undertreatment of pain.1 With improvements in pain management, however, came a rise in the number of adverse effects and outcomes, including unintentional overdose deaths.2,3 Studies have shown that the higher the dose of opioid prescribed, the greater the risk of morbidity and mortality associated with the drug regimen.4-6
More recently, many people have come to believe that Medicare’s patient satisfaction surveys may significantly impact opioid abuse. The reimbursement model is based on patient pain scores—an issue that, at times, seems to overshadow withholding opioids from certain patients who have an elevated medical or mental health risk.7 Common low-risk surgical procedures, such as tooth extraction and knee arthroscopy, are frequently the setting of opioid overprescribing by dentists and clinicians. Two recent articles in JAMA explore the trends in opioid prescribing among dentists and surgeons for postoperative pain.8,9
The new Centers for Disease Control and Prevention (CDC) opioid prescribing guidelines for primary care physicians have clearly set a national standard for opioid selection and dosing, cautioning prescribers to carefully assess and reassess the risks versus benefits of opioid therapy for each patient. Specifically, the guidelines note that primary care clinicians should avoid increasing a dosage beyond a threshold of 90 morphine milligram equivalents (MME) a day.10 In addition to the CDC, the Food and Drug Administration (FDA) and the National Institutes of Health (NIH) are taking a multipronged approach to address the opioid epidemic—from a beefed-up action plan to evaluate and approve new pain medications to a resolution for more pain management education to be taught in medical schools.11,12
These efforts are emphasized in the National Pain Strategy prepared by the NIH for the Department of Health & Human Services. The strategy includes six areas of pain care: population research, prevention and care, disparities, service delivery and reimbursement, professional education and training, and public awareness.13
Often overlooked in the recent discussion of medical pain management are the improvements in pain management that do not include opioids. These nonopioid medical advances have greatly impacted opioid use for the vast majority of new pain patients. For example, the adjuvant use of nonopioids has made it possible to reduce opioid dosages in the vast majority of cases.
The goal of this special edition of Practical Pain Management is to bring together experts in the field of medical pain management, pain psychiatry, and addiction medicine to present a blanced view of the current state of opioid prescribing and monitoring. We hope that this supplement will help primary care physicians better understand the rationale for opioid prescribing, when to use alternative therapies, how to properly assess and then monitor patients who are prescribed opioids, and perhaps most importantly, how to help patients who may get into trouble with opioids.
We hope you find this supplement helpful, and we look forward to your feedback.