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12 Articles in Volume 18, Issue #4
A New Frontier in Migraine Management: Inside CGRP Inhibitors & Migraine Prevention
Assessment of Patients with Rheumatoid Arthritis or Osteoarthritis
Biosimilars in Rheumatology: How Popular Will They Be?
Case Studies in Regenerative Cellular Therapy: Tendinopathy and Osteoarthritis
Commentary: Make the Easy Choice for Care
Editorial: The Emergence of Trackable Pill Technology: Hype or Hope?
Editorial: The Practicality of Pain Acceptance
How to Avert Government Scrutiny When Prescribing Opioids
Letters to the Editor: DEA and Prescribing, the War on Statistics, Failing Treatments, Patients' Options
Meet the Migraine Game-Changers
Platelet-Rich Plasma and Stem Cell-Rich Prolotherapy for Musculoskeletal Pain
With concerns over opioids, could novel receptors be useful?

Commentary: Make the Easy Choice for Care

June 1, 2018
More than six months after the declared national opioid public health emergency, misconceptions persist and much work remains to be done. Here’s where resources need to be redirected.

Necessary Distinctions

To fully grasp the current opioid overdose epidemic, and the lack of progress being made in fighting it, one must first understand the crucial distinction between opioid addiction and opioid physical dependence. The difference is frequently missed by the public and even by clinicians and researchers, leaving people to conflate the two conditions. “Addiction” is compulsively using a substance despite harmful consequences; “physical dependence” means the body physiologically needs the substance to function normally and without it, the individual will get physically ill. Patients living with chronic pain often experience opioid physical dependence and, despite having to take one or more opioids a day to effectively manage their pain, are not behaving in a way that causes dysfunction in their life.

Confusion around this distinction perpetuates stigma about the most effective treatment we have for opioid addiction, clinically termed opioid use disorder (OUD): long-term maintenance with the medications methadone and buprenorphine, both of which cause physiologic dependence while effectively treating addiction.

The onset of rising opioid-related deaths in the late 1990s was correlated with increased opioid prescribing and increased non-medical prescription opioid use. National surveys have found that the most common sources of non-medical prescription opioids used by individuals are friends and family members who obtained the prescription from their doctor. While a minority of patients who are prescribed opioids for pain develop an addiction, excess prescribing resulted in leftover pills in the community which ultimately contributed to the rise in non-medical prescription opioid use, and subsequently for some, opioid addiction.

Since 2012, however, the prominent driver of ongoing opioid-related deaths have been linked to heroin and, now, almost entirely fentanyl—not to prescribed opioids. The National Academies of Science highlighted this point in their 2017 report:1,2 “In more recent years, national initiatives to reduce opioid prescribing have modestly decreased the number of prescription opioids dispensed. However, many people who otherwise would have been using prescription opioids have transitioned to heroin use, with a resulting three-fold increase in heroin-involved overdose deaths from 2010 to 2014. Indeed, the overall frequency of heroin deaths has been accelerating since 2010.”

Just this spring, researchers at the US Centers for Disease and Control (CDC) acknowledged in an editorial that prescription opioid-related deaths have been over-reported by as much as half.3

The saying, “For every complex problem, there is an answer that’s clear, simple, and wrong,” comes into play here. Due to the rising death rates, despite the cause, many have simply called for an end to prescribing opioids, but in actuality, opioid prescribing has gone down and deaths have gone up.4 The origins of the opioid crisis, therefore, are clearly not the same as the factors currently sustaining it, and simply reducing the supply of prescription opioids may actually cause harm to people with opioid addiction as well as those with chronic pain.

Missed Targets

During the March 2018 White House Opioid Summit, President Trump called for increased law enforcement, including pursuit of the death penalty for “drug pushers” and legal action against “opioid companies."5 These statements are a diversion from what the country needs to focus on, and, in the case of the death penalty comment, deeply concerning. While some companies absolutely used shameful marketing techniques surrounding opioids in the past, it is not clear whether successful lawsuits would provide actual benefit to the current situation or direct earned funds where they are needed, which is in harm reduction and treatment programs.

Another challenge is the gap in scientific evidence for opioid use and efficacy. The fact that there have been essentially no long-term studies on opioids has led some to overstate what the medical community knows in this area or to apply what little research does exist to other scenarios. For example, some studies have shown that voluntary opioid tapers result in improved quality of life and functional status, but these results are very different from forcing a patient off his or her medication, and the approach should not be applied as a one-size-fits-all solution. Involuntarily tapering someone off opioids may have very negative consequences, including growing anecdotal reports of suicide. While the CDC Guidelines6 on opioid prescribing offer useful guidance, they are meant to be interpreted by individual clinicians with individual patients in mind and do not support involuntary tapers.

Like all illnesses, the context of treating the individual patient—who is at the center of the illness—must factor in any comorbidities or psychosocial circumstances in order to be effective. In addition, there is an important difference between:

  • a patient for whom a provider is considering whether to newly initiate chronic opioid therapy; and
  • a patient with a diagnosed chronic pain condition(s) who has been managed for years with opioids, feels they are effective, and is not interested in changing his or her treatment plan.

The National Academies of Science report1 highlighted this difference and the complexities in healthcare management, describing the “large group of ‘legacy’ chronic pain patients [who] are receiving opioids at doses or under circumstances that are inappropriate in light of current knowledge. Information useful in understanding how best to manage this group of patients is lacking.”

Beneficial Investments

Driving the current death toll are overdoses caused by illicit heroin and fentanyl use, often among people with untreated severe opioid use disorder. People with severe OUD, or addiction, need immediate access to treatment, which includes medications and harm reduction interventions to reduce the imminent risk of death. The government and the public need to understand that addiction—whether to alcohol, tobacco, or opioids—is a chronic illness, one that, with treatment, will result in remission for most people. However, it is a gradual process toward health with expected recurrences of use along the way. Immediate access to science-based treatment and harm reduction at every point will increase the likelihood of recovery and reduce the risk of death.

Canada released in March 2018 a set of national guidelines7 for addressing OUD. These science-based recommendations include a blueprint for patient care that could easily be applied in the United States. In the meantime, states across the country have the opportunity to be incubators—that is, to think in-depth about the issue and to implement programs at a faster speed than the federal government. By identifying who is suffering and making treatment available, states can make treatment the easy choice and keep people safe using science, not opinions.

Overall, thoughtful opioid prescribing and provider training are crucial steps toward ending the opioid overdose and addiction crisis. Physicians must understand how to best proceed if a concern arises regarding a patient’s potential opioid use disorder. The answer should never be to simply stop treating the patient or turn the patient away, but rather to use available tools to provide effective care both for addiction and for pain.

Last updated on: April 12, 2019
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