It has been over 200 years since doctors first crystallized morphine for use as a pain management medication. In 2015, many other forms of the opioid morphine exist. For many years now opioids have been one of the first medications a doctor reached for when confronted with a patient’s acute or chronic pain. After all, in most cases, patients felt immediate relief, and for a time there was not overwhelming evidence as to the dangers of opioids. Some patients reported dependence and ineffectiveness in pain management after just a brief use, but for many others, opioids seemed to be a pain-relieving miracle in a bottle.
For much of their existence, opioids were used only for severe pain or briefly for post-operative pain. In the 1990s, some advocates for opioids argued that they could be used to safely treat other types of pain. In 1995, the FDA approved OxyContin, one of the most widely-prescribed opioid painkillers. The manufacturer of OxyContin eventually pled guilty and paid over $600 million dollars in fines for misleading marketing, but the die was cast and prescriptions for opioids continued to rise.
This reliance on opioids was not because doctors didn’t care about potentially harmful consequences. Only recently has research shed light on issues such as over-prescription, dependence, and ineffectiveness over time. Opioid overdose now causes more deaths than heroin and cocaine combined. Some organizations place the blame squarely at the feet of drug manufacturers. Andrew Kolodny of Physicians for Responsible Opioid Prescribing wants the U.S. Food and Drug Administration to severely limit the marketing and prescription of opioids for all but severe pain and palliative care conditions. He states in a Review-Journal article:
“Over the past decade, there have been more than 125,000 painkiller overdose deaths because drug companies were permitted to falsely advertise these drugs as safe and effective for long-term use.”
Physicians across the country are now aware of this issue and responding in their communities. A survey sent out to internists, family physicians, and general practitioners in February 2014 had a 58% return rate. The statistics gathered from this representative sample included the following:
- 85 percent of the respondents say that opioids are overused in clinical practice
- Many reported they are “very” or “moderately” concerned about serious risks, such as addiction (55 percent reporting “very concerned”), death (48 percent), and motor vehicle crashes (44 percent) that may be associated with opioid abuse
- Many also reported they believe that drug-related physical problems, such as tolerance (62 percent) and physical dependence (56 percent), occur “often,” even when the medications are used as directed for chronic pain
While this survey indicates that physicians recognize the seriousness of the issue, 88% of those returning surveys believe that they are capable and cautious prescribers of opioids. They feel that their colleagues are swayed by marketing materials and drug rep visits but that they themselves are immune.
Pain specialists are working hard to turn the tide and tame the flow of opioids into pain management systems. Because they deal strictly with all aspects of pain, they are uniquely equipped to work with different therapies, rather than turning first to opioids. Richard W. Rosenquist, MD, Chairman of Cleveland Clinic’s Department of Pain Management believes that “Today, pain specialists rarely prescribe opioids for chronic pain unless it’s cancer-related.”
The American Academy of Pain released a study in 2013 that outline the dangers of long-term opioid use. In addition to the risk of addiction, long-term use of opioids poses other risks, such as:
- Loss of muscle mass
- Decreased libido
- Increased risk of infection
- Hyperalgesia (increased sensitivity to pain)
Because of these risks, it is important to thoroughly evaluate each patient to determine if the use of opioids is indicated. Nevada Pain uses a 12-step checklist when considering prescribing opioids for pain management. Our twelve steps are:
- Assessment of pain (0-10 scale)
- Clear documentation of rationale for opioid use (i.e., chronic lower back pain, degenerative disc disease)
- Clear documentation of beneficial clinical response to opioid use (i.e., decrease pain or increase function)
- Established goals of opioid treatment and review of goals (i.e., patient has an increased ability to function)
- Current and updated medication list
- Documentation of substance abuse/social history (i.e., patient denies any history of T/E/D prescription medications)
- Physical examination of painful area
- Documentation of risks and benefits (i.e., risks explained to patient)
- Appropriate referral for additional evaluation and treatment (i.e., psychiatric referral for depression)
- Updated Pharmacy Board review
- Current and consistent UDS within last 30 days
- Signed an Opioid Agreement within last six months
It is important to note that ongoing counseling and consistently re-evaluating the need for opioids are a large part of the 12-step checklist. If a patient responds well to opioids and is able to move to other therapies that don’t involve prescriptions, Nevada Pain will respond and change the treatment plan.
Maintaining the delicate balance between over-prescription and making opioids available to people for whom they work is an important part of the conversation. Food and Drug Administration Commissioner Margaret Hamburg points out that:
“…we have an important balancing act of trying to assure that safe and effective drugs are available for patients who have real pain and need medical care.”
The FDA now requires new, strongly worded labeling for OxyContin that specifies its use only for pain requiring “…daily, around-the-clock” therapy with no other effective pain control method.
Nevada Pain believes that opioids can be part of an effective pain management strategy for some patients. We also believe in looking for holistic treatments to address not only the symptoms of pain but also the underlying causes. We support the balance of continued research into proper, safe, and effective use of opioids and the best possible treatment for our patients.
What do you think about the new laws and public opinions surrounding opioids?
Image by Melanie Tata via Flickr