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   NEWS & PERSPECTIVE › MULTISPECIALTY   
      
      
   US Opioid Epidemic Fueled by Prescribing Practices   
   Pam Harrison   
   September 28, 2015   
       
   The United States is facing the worst "man-made epidemic" of opioid abuse in   
   the history of modern medicine, and it is the direct result of poor research   
   and outdated teaching practices, according to a leading pain expert.   
      
   "There's been over 200,000 deaths from prescription opioids and many more   
   hundreds of thousands of overdose admissions, and millions are addicted or   
   dependent on prescription opioids, and while some patients don't meet the   
   classic definition of opioid    
   use disorder, as many as 30% of patients who are sitting across from you in   
   your office have opioid use disorder or are severely dependent," Gary   
   Franklin, MD, MPH, vice president of Physicians for Responsible Opioid   
   Prescribing, said during a Webinar    
   sponsored by the Centers for Disease Control and Prevention's Clinician   
   Outreach and Communication Activity (COCA).   
      
   "So this is an extremely serious epidemic, and while I know that taking care   
   of these patients is not an easy thing to do, we need to reduce overdose   
   deaths and admissions, and we have ways to reverse trends which we all need to   
   embrace."   
      
   The most important step toward reversing the epidemic of prescription opioid   
   abuse is to stop prescribing opioids for the wrong indications.   
      
   Recent reports have consistently concluded that there are insufficient data on   
   the long-term effectiveness of prescription opioids to support their use in   
   the treatment of chronic pain, but there is clear evidence of a dose-dependent   
   risk for serious    
   harms.   
      
   The biggest triggers to the initiation and perpetuation of prescription opioid   
   abuse comes from their use for the treatment of nonspecific musculoskeletal   
   disorders, especially chronic low back pain, headaches, and disorders such as   
   fibromyalgia.   
      
   Although there is no proven benefit for their use in these disorders, "people   
   with these indications are on chronic opioids, and they have become disabled,   
   and they are spilling over into social security and disability systems," Dr   
   Franklin said.   
      
   In recognition of this problem, the American Academy of Neurology and a number   
   of states, including Washington, have produced guidelines that advise that in   
   general, opioids should not be routinely used for the treatment of   
   musculoskeletal conditions,    
   headache, or fibromyalgia.   
      
   "Not only is there no evidence to support their use in these conditions, there   
   is quite a bit of evidence against doing so, and these are probably the most   
   routine patients we have who are on chronic opioids and who have become   
   dependent and addicted to    
   them in our country," Dr Franklin said.   
      
   Indeed, in a 2008 study conducted by Dr Franklin and colleagues (Spine.   
   2008;33:199-204), results showed that 14% of workers who sustained a low back   
   injury were disabled at 1 year and that receiving opioids for at least 7 days   
   at a cumulative dose of    
   150 mg morphine equivalent dose (MED) doubled the risk of being on disability   
   1 year later, after adjusting for baseline reported pain, function, and injury   
   severity.   
      
   Dosing Guidance   
      
   The issue of the MED and the risk for an overdose event, either    
   ospitalization or death, is also extremely important in community efforts to   
   reduce the risk for opioid-induced harm.   
      
   Recent evidence suggests that there is a dramatic increase in death when   
   opioids are administered at a dose of 100 mg MED ― "but the risk of overdose   
   is also two- to fivefold higher when that same opioid MED runs between 50 and   
   99 mg MED," Dr Franklin    
   said.   
      
   "So you need to be paying a lot more attention to lower doses of opioids and   
   never go over 100 mg MED."   
      
   This is particularly important for patients who are receiving a combination of   
   an opioid and either a benzodiazepine or another sedative-hypnotic or muscle   
   relaxants, all of which can dramatically add to the risk for opioid harm, even   
   at lower doses of    
   opioids, he added.   
      
   Dr Franklin also cautioned that the intermittent use of opioids does not spare   
   patients from overdose and that in doses lower than 100 mg MED, many patients   
   enrolled in Washington State's Medicaid program have been admitted for opioid   
   overdose even when    
   they were not using opioids on a long-term basis.   
      
   Comprehensive guidelines from Washington State on prescribing opioids make it   
   very clear that physicians must proceed with caution when initiating opioid   
   therapy to improve function and pain in patients with chronic pain or when   
   transitioning to the long-   
   term use of opioids.   
      
   Before initiating treatment with any opioid, patients should be screened for   
   current or past substance abuse as well as depression.   
      
   Clinically Meaningful Improvement   
      
   "When you are tracking pain and function, you also have to make sure there is   
   clinically meaningful improvement in both pain and function," said Dr Franklin.   
      
   In Washington State, a clinically meaningful improvement in pain and function   
   means at least a 30% improvement in both.   
      
   Physicians also need to track pain and function at every visit so that they   
   can better judge how well the opioid may be working — or not.   
      
   Sleep disturbances are common in patients with chronic pain, and physicians   
   need to help patients with various measures to improve sleep hygiene or   
   prescribe a tricyclic antidepressant, which will help with underlying   
   depression as well sleep    
   disturbances, he added.   
      
   There are also many nonpharmacologic alternatives to long-term opioid use that   
   are strongly supported by evidence.   
      
   Graded exercise is well established as a good treatment modality for chronic   
   pain, as are cognitive-behavioral therapy (CBT), mindfulness-based stress   
   reduction techniques, and various forms of meditation and yoga.   
      
   If patients who are currently receiving opioids are scheduled for an elective   
   operation, they should resume their preoperative dose of opioids 6 weeks after   
   surgery.   
      
   If they are not receiving opioids at the time of the procedure, patients   
   should be off all opioids within 6 weeks.   
      
   And if patients are not improving on opioid therapy, "the ongoing risk from   
   continued treatment outweighs the benefit," Dr Franklin said.   
      
   "And opioids in these patients should be tapered to zero."   
      
   The new guidelines indicate that when tapering opioids, the dose should be   
   reduced by 10% a week, with or without accompanying CBT, inpatient   
   detoxification, or treatment in a pain clinic.   
      
      
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