The Role of Prescribers in the Opioid Epidemic
The 10 year epidemic of opioid abuse has had a key contribution from physicians, dentists and other opioid prescribers who have overused chronic opioids for pain relief. This use of chronic opioids for benign but chronic pain conditions such as low back pain, headache, peripheral neuropathies and fibromyalgia has produced opioid tolerance and dependence as well as hyperalgesia in patients with these conditions. The estimated percentage of these patients who have gone on to develop addiction with its aberrant behaviors has been as low as 15% to as high as 80% depending on the clinical setting such as geriatric primary care versus AIDS treatment clinics. Some statistics include that prescriptions for opioids grew from about 76 million in 1991 to nearly 207 million in 2013 and that 15.3 million opioid prescriptions were written from primary care physicians in 2013 for Medicare patients alone.
The Cost of Opioid Abuse
Over 2 million Americans have opioid use disorder based on using prescription painkillers in the past year. Physicians have been publically blamed “for the nation’s epidemic of opiate addiction about as much as the public holds individuals responsible for abusing the medications.” These opioids not only are used and abused by pain patients themselves, but also are abused by the children of parents who are given excessive supplies of opioids and do not dispose of these supplies. Since 2005 the most common illicit drug that is first used by children is no longer marijuana, but is pain relievers like hydrocodone. Annual opioid dependence-related costs exceed $55 billion. The morbidity and mortality costs have also been substantial with a rise in emergency department visits due to opioids of over 300% since 1995, and 78 people dying daily from opioid overdose. Overdose is the most serious complication of this epidemic and naloxone administration by non-medical persons has been widespread as a way to prevent opioid overdose deaths. An intranasal naloxone administration device has been developed that is easy to use and relatively inexpensive.
Since 2005 the most common illicit drug that is first used by children is no longer marijuana, but is pain relievers like hydrocodone.
Two longer term complications of chronic opioid use are tolerance and hyperalgesia.
Due to tolerance, chronic opioid use decreases endurance of deep pain (as assessed with a cold pressor test) and relief is provided by giving more opioids. Thus, escalating doses of opioids will be needed when given regularly for over 3 months even if pain does not increase over time.
Hyperalgesia is simply that relatively minor pains will be amplified in their intensity when opioids are taken chronically. Thus, chronic opioid use will actually increase pain.
Addiction to opioids is another complication and can be manifested by a variety of aberrant behaviors such as:
- Selling prescription drugs
- Prescription forgery
- Stealing or borrowing another patient’s drugs
- Injecting oral formulations of opioids
- Obtaining prescription drugs from non-medical sources
- Concurrent abuse of related illicit drugs
- Multiple unsanctioned dose escalations
- Recurrent prescription losses.
These aberrant behaviors do not always indicate criminal intent; they can also reflect self-medication of psychiatric problems such as depression and anxiety disorders. To prevent opioid abuse with chronic benign pain treatment, do not use opioids for more than 60 days and collect urine toxicologies for non-prescribed opioids in any patient suspected of abuse or diversion.
Effective Opioid Addiction Treatment
For patients who develop problems with opioid addiction, detoxification is often needed and contemporary approaches can use clonidine, naltrexone and buprenorphine. Clonidine plus naltrexone can reduce the severity of opioid withdrawal while substantially reducing the severity and duration of symptoms from 15 days to 4 days.
The goal of treatment is to prevent relapse to illicit opioid use and three agents are worth consideration; Naltrexone, Methadone and Buprenorphine.
Naltrexone blocks μ-opiate receptors, blocks euphoria from opioids and can be used orally or by monthly depot injection. In comparing oral to depot naltrexone, long-acting injectable naltrexone produced significantly better outcomes than oral naltrexone on days retained in treatment and proportion of opiate-free urines.
Methadone is an opiate agonist, which produces cross-tolerance at high doses such that the patient’s level of opioid dependence becomes significantly greater after methadone treatment and the detoxification can be harder.
Buprenorphine is a partial opiate agonist, which blocks euphoria at high doses (8 mg daily), but unlike naltrexone, it can be started at low doses and relieve opioid withdrawal without needing to endure an opioid detoxification.
There are many effective psychosocial interventions to be used with these medications. More prescribers are needed as well as coordinated work among medical and behavioral health providers.