What’s Up with Opioids?
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By now I’m sure you’ve heard about the “opioid epidemic” and some of the concerns about prescribing opiods for chronic pain. In this blog post, we’ll take a closer look at these issues to understand the importance of the Centers for Disease Control and Prevention (CDC) guidelines that providers at Desert Spine and Sports Physicians are following.
The National Institute of Health (NIH) nicely summarizes opioids:
“Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine, and many others. All opioids are chemically related and interact with opioid receptors on nerve cells in the body and brain. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription). Regular use – even as prescribed by a doctor – can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose incidents and deaths.”
Let’s clarify the terms tolerance, dependence and addiction which are often mentioned when discussing opioids. Tolerance means the body has a diminished response to a drug due to prolonged use. For example, the patient has to take higher doses of medication (i.e. oxycodone 4x/day instead of 2x/day) to achieve the same results. Dependence is another issue. This occurs when the body needs a certain amount of the drug or otherwise the patient will have withdrawal symptoms. With opioid withdrawal, one may have diarrhea, nausea, runny nose, body aches, etc. While these symptoms are unpleasant, they are not life threatening. Another example of dependence is people needing their morning coffee, without which they get a headache. Drinking coffee prevents the headache which is a symptom of caffeine withdrawal. Tolerance and dependence do not necessarily mean someone is addicted, but it can lead to addiction. Addiction is a medical condition characterized by compulsive drug seeking and use despite harmful consequences in regards to work, social or interpersonal issues.
In March 2016, The CDC published guidelines1 for prescribing opiates for non-cancer chronic pain. Some of the pertinent guidelines include: 1) Non-pharmacologic therapy (i.e. physical therapy and spinal injections) and non-opioid medications are preferred for chronic pain; 2) When opioids are prescribed, they should be used at the lowest effective dosage; 3) When opioids are used for acute pain (which may lead to chronic opioid use), clinicians should prescribe the lowest effective dose for no more than 3-7 days maximum; 3) Clinicians should review the patient’s history of controlled prescriptions using state prescription monitoring program data when starting and refilling opioid therapy; 4) Clinicians should avoid prescribing opioid medications and benzodiazepines (i.e. Xanax) concurrently as together they increase risk of respiratory depression and death; 5) For chronic pain, providers should evaluate risk and benefits of opioid therapy at least every 3 months, and if no improvement in pain and functionality should taper off opioids and optimize other therapies; and 6) For chronic pain, providers should use urine drug testing before starting and at least annually thereafter to assess for prescribed medications, other controlled prescription drugs, and illicit medications.
These guidelines are largely based upon the lack of any studies that have found that opiates improve pain or function in patients with chronic non-cancer pain. In fact, in our monthly multi-disciplinary journal club, we reviewed a large clinical trial1 on the effect of opioid vs non-opioid medications on pain-related function in patients with chronic (>3 months) moderate to severe lower back pain or hip or knee arthritis. This study found that treatment with opioids was not superior to treatment with non-opioid medications (i.e. Tylenol and NSAIDS) for improving pain-related function over 12 months. In addition, pain intensity was significantly better in the non-opioid group. The results did not support starting opioid therapy for moderate to severe chronic back pain or hip or knee pain from osteoarthritis.
Despite these guidelines, the CDC recently published a recent alarming report in March 2018 showing that overdose deaths unfortunately continue to rise. Drug overdoses killed 63,632 Americans in 2016. Almost two-thirds of those deaths involved prescription or illicit opioids. Furthermore, prescription opioid-related overdoses increased by 10.6% over one year. These staggering statistics emphasize the extreme need for providers to educate their patients about the significant risks of these medications and furthermore, to prescribe them in a judicious manner following as close as possible to the CDC guidelines and other state guidelines where they exist.
Here at Desert Spine and Sports Physicians, we strive to manage pain by delivering comprehensive, compassionate, and innovative medical care that is evidence-based i.e. supported by medical literature. We offer the full spectrum of non-operative treatments for spine, sports, and musculoskeletal pain and injury including on-site physical therapy, fluoroscopically and ultrasound-guided injections, and medications when appropriate. We recognize that opioid medications may have a role in managing pain, particularly acute pain that is not responding to treatments like OTC and prescription non-opiate medications, physical therapy, or injections. When prescribing these medications, we discuss the risks and benefits with our patients, and abide by the CDC and Arizona guidelines to the best of our abilities. Together, it is our hope that providers and patients work together as a team to manage pain appropriately and safely and in the end, help tackle this opioid epidemic.
2Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopiod Medications on Pain-Related Function in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain. The SPACE Randomized Clinical Trial. JAMA. 2018 Mar; 319(9):872-882.
Opioid prescription fact sheet: https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf
Confidential national hotline for individuals and families affected by substance abuse: 1-800-662-HELP (4357)