Lown Right Care

Reducing Overuse and Underuse

Appropriate Use of Opioids for Chronic Pain

 

Am Fam Physician. 2020 Sep 15;102(6):335-337.

Author disclosure: No relevant financial affiliations.

Case Scenario

Mrs. H is a 76-year-old woman with hypertension and type 2 diabetes mellitus complicated by stable chronic kidney disease. Mrs. H also has a degenerative joint disease of the knees and walks with a cane. Her mobility and quality of life are significantly limited by knee pain. Physical therapy, heat, acupuncture, and steroid injections have provided insufficient relief. Nonsteroidal anti-inflammatory drugs (NSAIDs) were discontinued because of kidney disease. Several years ago, Mrs. H's family physician prescribed 5 mg of oxycodone every six hours as needed, and a standing dose of 650 mg of acetaminophen every six hours. This regimen, with range of motion exercises and application of heat, has improved pain and function without adverse effects. Mrs. H takes two to four oxycodone doses per day and has not needed more than the 100 pills prescribed each month. At a recent visit, her physician told her that because of the opioid epidemic and scrutiny by the state medical licensure board, he is no longer comfortable prescribing opioids for her chronic pain. He refers Mrs. H to a pain management specialist. However, when Mrs. H calls several pain specialists' offices, she is told that they no longer accept new patients, only do interventional procedures, or no longer prescribe opioids.

Clinical Commentary

The opioid epidemic in the United States coincided with a steady increase in national opioid prescriptions, peaking in 2012 at more than 255 million, or a rate of 81.3 prescriptions per 100 people.1 Opioid prescribing declined between 2012 and 2017 to 191 million, or 58.7 prescriptions per 100 people.1 In 2017, more than 70,000 people died from drug overdoses (47,600 involving opioids), making it the leading cause of injury-related death in people 25 to 64 years of age.2,3corrected Contributing causes include aggressive pharmaceutical industry marketing, indiscriminate prescribing by clinicians, pressure from regulatory agencies to control pain and improve patient satisfaction, patient misuse and diversion, and increased use of illicit drugs such as heroin and fentanyl.4

Chronic pain is pain that has lasted for longer than three months or the time of normal tissue healing.5,6 Nonpharmacologic treatment options include physical therapy, manipulative medicine, acupuncture, and cognitive behavior therapy. Pharmacologic approaches include opioid and nonopioid analgesics in addition to adjuvant medications such as anticonvulsants, antidepressants, and muscle relaxants.7 The use of nonopioid medications is often restricted by limited effectiveness or adverse effects, such as bleeding, strokes, and cardiovascular and renal disease with NSAIDs.8 Adjuvant medications such as gabapentin (Neurontin) have been used for nonapproved indications (e.g., bone and joint pain) with little evidence of effectiveness.9 These medications are also associated with numerous adverse effects, drug-drug interactions, and the potential for misuse.10

In 2016, the Centers for Disease Control and Prevention (CDC) published guidelines for prescribing opioids for chronic noncancer pain based on an Agency for Healthcare Research and Quality systematic review and expert opinion.11,12 These guidelines were intended for primary care clinicians, who account for approximately one-half of all opioid prescriptions.13 The American Academy of Family Physicians gave the guidelines an Affirmation of Value but did not fully endorse them because of the limited or insufficient evidence to support some recommendations.14

In response to the CDC guidelines, media attention, and increased regulatory scrutiny, many physicians have stopped prescribing opioids for chronic pain. Abrupt opioid discontinuation has left patients with the inability to function, led to opioid withdrawal or pain crises, and caused some to seek relief from illicit opioids.15,16 In 2019, the lead authors of the CDC guidelines clarified that their intention was not to set hard limits on daily opioid doses or cause clinicians to abruptly taper or stop prescribing opioids to patients with chronic pain.17

A systematic and commonsense approach to pain management is essential. Appropriate treatment of acute pain, including the use of short-acting opioids when indicated in the lowest possible dose for less than seven days, may decrease

Address correspondence to Alan R. Roth, DO, at aroth@jhmc.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. Centers for Disease Control and Prevention. Opioid overdose: understanding the epidemic. Accessed July 20, 2020. https://www.cdc.gov/drugoverdose/epidemic/index.html...

2. Scholl L, Seth P, Karissa M, et al. Centers for Disease Control and Prevention Drug and opioid-involved overdose deaths - United States, 2013-2017 MMWR Morb Mortal Wkly Rep. 2019;67:1419-1427.

3. Centers for Disease Control and Prevention. Injury prevention and control: leading causes of death and injury. Accessed July 20, 2020. https://www.cdc.gov/injury/wisqars/LeadingCauses.html

4. U.S. Department of Health and Human Services. What is the U.S. opioid epidemic? Accessed February 27, 2020. https://www.hhs.gov/opioids/about-the-epidemic/index.html

5. Institute of Medicine Committee on Advancing Pain Research, Care, and Education. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. The National Academies Press; 2011.

6. International Association for the Study of Pain. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Pain Suppl. 1986;3:S1–S226.

7. Centers for Disease Control and Prevention. Nonopioids treatments for chronic pain. Accessed July 21, 2020. https://www.cdc.gov/drugoverdose/pdf/nonopioid_treatments-a.pdf

8. Marcum ZA, Hanlon JT. Recognizing the risks of chronic nonsteroidal anti-inflammatory drug use in older adults. Ann Longterm Care. 2010;18(9):24–27.

9. Goodman CW, Brett AS. Gabapentinoids for pain: potential unintended consequences. Am Fam Physician. 2019;100(11):672–675. Accessed July 20, 2020. https://www.aafp.org/afp/2019/1201/p672.html

10. Peckham AM, Evoy KE, Ochs L, et al. Gabapentin for off-label use: evidence-based or cause for concern? Subst Abuse. 2018;12:1178221818801311.

11. Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain — United States, 2016 [published correction appears in MMWR Recomm Rep. 2016;65(11):295]. MMWR Recomm Rep. 2016;65(1):1–49.

12. Chou R, Deyo R, Devine B, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. Evid Rep Technol Assess (Full Rep). 2014;(218):1–219.

13. Levy B, Paulozzi L, Mack KA, et al. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007–2012. Am J Prev Med. 2015;49(3):409–413.

14. American Academy of Family Physicians. Clinical practice guideline(s): opioid prescribing for chronic pain. Accessed February 26, 2020. https://www.aafp.org/patient-care/clinical-recommendations/all/opioid-prescribing.html

15. Kroenke K, Alford DP, Argoff C, et al. Challenges with implementing the Centers for Disease Control and Prevention opioid guideline: a consensus panel report. Pain Med. 2019;20(4):724–735.

16. Rich RL Jr. Prescribing opioids for chronic pain: unintended consequences of the 2016 CDC guideline. Am Fam Physician. 2020;101(8): 458–459. Accessed July 13, 2020. https://www.aafp.org/afp/2020/0415/p458.html

17. Dowell D, Haegerich T, Chou R. No shortcuts to opioid prescribing. N Engl J Med. 2019;380(24):2285–2287.

18. Nuckols TK, Anderson L, Popescu I, et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2014;160(1):38–47.

19. U.S. Department of Health and Human Services. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of long-term opioid analgesics. October 2019. Accessed February 22, 2020. https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf

20. Lembke A, Humphreys K, Newmark J. Weighing the risks and benefits of chronic opioid therapy. Am Fam Physician. 2016;93(12):982–990. Accessed March 1, 2020. https://www.aafp.org/afp/2016/0615/p982.html

21. Lemke A. Tapering long-term opioid therapy. Am Fam Physician. 2020;101(1):49–52. Accessed March 1, 2020. https://www.aafp.org/afp/2020/0101/p49.html

22. Reuben DB, Alvanzo AAH, Ashikaga T, et al. National Institutes of Health Pathways to Prevention Workshop: the role of opioids in the treatment of chronic pain. Ann Intern Med. 2015;162(4):295–300.

23. Barnett ML. Opioid prescribing in the midst of crisis – myths and realities. N Engl J Med. 2020;382(12):1086–1088.

24. Centers for Disease Control and Prevention. Prescription opioids: what you need to know. Accessed July 21, 2020. https://www.cdc.gov/drugoverdose/pdf/aha-patient-opioid-factsheet-a.pdf

25. Mayo Clinic. Patient care and health info. Opioids and other drugs: what to watch for. Accessed July 21, 2020. https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/expert-answers/opioids-interactions/faq-20381271

26. U.S. Food and Drug Administration. Consumer updates. Acetaminophen: avoiding liver injury. Accessed July 21, 2020. https://www.fda.gov/consumers/consumer-updates/acetaminophen-avoiding-liver-injury

27. U.S. Food and Drug Administration. Medication guide for nonsteroidal anti-inflammatory drugs (NSAIDs). Accessed July 21, 2020. https://www.fda.gov/media/72932/download

28. Samuel E. Safe Kids Worldwide. How to keep kids safe around medicine. March 15, 2018. Accessed July 21, 2020. https://www.safekids.org/blog/how-keep-kids-safe-around-medicine

29. Lown Institute. Medication overload: implement prescription checkups. January 28, 2020. Accessed July 21, 2020. https://lowninstitute.org/reports/medication-overload-implement-prescription-checkups/

Lown Institute Right Care Alliance is a grassroots coalition of clinicians, patients, and community members organizing to make health care institutions accountable to communities and to put patients, not profits, at the heart of health care.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Lown Right Care published in AFP is available at https://www.aafp.org/afp/rightcare.

 

 

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