When to Use Opioids: What I Didn't Learn in Medical School
It is almost impossible to look at the news or the medical literature today and not see a story related to the rising rate of opioid prescriptions or the almost epidemic jump in opioid overdose deaths. More than 125 papers have been published on the topic since January 2016 alone.
There are many factors driving this public health crisis, from the increasing prevalence of pain in the general population to the influence of the pharmaceutical industry in popularizing opioids for the treatment of chronic pain to the liberalizing of pain treatment.1 Currently, about 30% of Americans report experiencing some type of acute or chronic pain.2 In 2014 alone, US pharmacies dispensed 245 million prescriptions for opioid medications.2 Accompanying this growth in prescriptions has been a surge in misuse and abuse of the drugs, with opioid overdose now a leading cause of accidental death in the US—second only to motor vehicle crashes.3 Of drug overdose deaths, more than a third (37%) reported in 2013 were attributable to pharmaceutical opioids.2 In addition, substance abuse treatment admissions for opioids other than heroin have increased more than sixfold between 1999 and 2009.4
Despite these troubling statistics, many physicians report that they are not confident in their knowledge of how to prescribe opioids safely, detect abuse or addiction, or initiate a conversation regarding these issues with their patients.2 Nevertheless, the standards for managing pain and medication abuse are becoming tighter and putting both prescribers and patients in jeopardy. This is why, now more than ever, we must improve awareness and education regarding appropriate opioid use.
Very few medical schools currently provide training in pain management, and fewer still provide courses in addiction beyond abuse of illicit substances and alcohol.2 A study looking at emergency physicians in both Georgia and Florida in 2013 revealed that 22% of the participants reported that they had not received any training regarding opioid management and screening for abuse.5
Knowing the pharmacology and metabolism of a drug, unfortunately, does not translate into knowing how to use it appropriately. The Office of National Drug Control Policy recognizes this knowledge gap and is encouraging improved education for both medical students and physicians currently in practice with a Drug Enforcement Agency (DEA) license.5 The general consensus is that teaching and training practices for physicians, nurse practitioners/physician assistants (NP/PAs), nurses, dentists, and pharmacists should be enhanced in the areas of pain management, opioid pharmacology, and abuse or addiction. Such training could be achieved through web-based programs and continuing medical education (CME), and is becoming a part of the requirements for licensure in several states.1-3 But even web-based training would likely offer or require only limited CME hours. So while this might raise awareness amongst clinicians, it certainly will not make them experts. Unfortunately, an overemphasis on abuse and prevention may limit how well and how often prescribers employ opioids.
When and How to Prescribe Opioids
Just as all forms of hyperglycemia do not warrant insulin use, not all pain needs opioid treatment. Some patients will do fine with nonpharmacological techniques, and many others will have contraindications to chronic opioid treatment. It is best to try nonopioid analgesics, alongside behavioral modification, before resorting to opioids.
For the past 20 years, the increased involvement of pharmaceutical manufacturers in medical education and marketing has changed both the perception and prescribing practices of opioids in the US. The real change came in the 1990s when the marketing of opioids for the treatment of moderate to severe, chronic noncancer pain led to a stark increase in prescriptions.1 In 2007, a pharmaceutical company pleaded guilty in US federal court to criminal charges that it misled both doctors and patients in claiming its controlled-release opioid was a safe alternative to other opioids.6
No high-quality studies have evaluated opioid therapy compared to no opioid therapy for long-term (>1 year) outcomes in chronic pain.4 Randomized controlled trials (RCTs) and double-blinded studies would be challenging and perhaps unethical; what patient with moderate to severe pain would agree to being randomized to a placebo arm for longer than 1 year? Many 12-week RCTs and open label extension studies longer than 6 months are available to gauge efficacy and long-term effectiveness.
In the absence of sufficient longer-term evidence, the general consensus is that alternative (nonpharmacologic as well as pharmacologic) therapies should be tried prior to initiating opioid agents for chronic noncancer pain.2,4,7 Nonpharmacologic therapies that have been useful in treating chronic pain include cognitive behavioral therapy (CBT), exercise therapy, yoga, massage, meditation, and acupuncture. These modalities can be combined with pharmacologic therapy, such as nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, and anticonvulsants, as well as interventional therapies, such as epidural injections, biofeedback, and nerve stimulators.2,7
If all of these modalities prove inadequate to control pain, opioid therapy may be added. In the short run, this will likely be more labor intensive for prescribers and may result in more patient dissatisfaction. However, in the long run, clinicians and patients must learn that not all pain requires prescribing controlled substances and, like for many other diseases, lifestyle modifications are at least as, and often more, desirable than medication management.
The majority of prescriptions for opioids today are actually limited to the treatment of acute noncancer pain.1,7 Such use could be minimized as well by looking at both time limits to therapy and the use of other modalities. Most mechanical joint pain, for example, is time limited and does not warrant opioid use.
Before prescribing opioid medications, it is important to know how to screen for opioid misuse and abuse. There are certain factors that place patients at higher risk for abuse, including a history of opioid abuse or major depressive disorder, ongoing psychotropic medication use, reports of higher pain scores, and poorer health status.8 Prior to initiating opioids for chronic pain management, patients should be screened for substance use disorders with tools such as the Opioid Risk Tool (ORT) or the Screener and Opioid Assessment for Patients with Pain (SOAPP). In addition, providers should utilize state prescription drug monitoring programs (PDMP) to identify patients who are “doctor shopping” for pain medications, as well as administer a urine drug screen prior to prescribing and throughout the course of treatment to assess for illicit drug use.2,7