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Continuing Education for Health Professionals

Opioids as Medications

Module 9

Overdose from Prescription Opioid Pain Relievers

The Centers for Disease Control and Prevention (CDC) has declared an epidemic of overdoses from prescription opioid pain relievers (OPR) and has published several papers on the topic, including new guidelines for prescribing opioids for chronic pain (CDC, 2011a, 2011b, 2016).

Deaths from prescription painkillers—opioid pain relievers such as Vicodin (hydrocodone), OxyContin (oxycodone), Opana (oxymorphone), and methadone—have reached epidemic levels in the past decade. The number of overdose deaths is now greater than those of deaths from heroin and cocaine combined. From 1999 to 2014, more than 165,000 people died from an opioid overdose in the United States. The biggest problem is the use of medications without a prescription just for the “high” they cause. In 2010 as many as 12 million Americans (age 12 or older) reported nonmedical use of prescription painkillers in the previous year.

Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month. Although most of these pills were prescribed for a medical purpose, many ended up with others who misused or abused them. Improving the way painkillers are prescribed can reduce the abuse or overdose from these powerful drugs while making sure patients have access to safe, effective treatment. The CDC (2011a) released the following information.

Prescription Painkillers in the United States

Prescription painkiller overdoses are a public health epidemic.
  • Prescription painkiller overdoses killed nearly 15,000 people in the United States in 2008. This is more than 3 times the 4,000 people killed by these drugs in 1999.
  • In 2010 about 12 million Americans (age 12 or older) reported nonmedical use of prescription painkillers in the past year.
  • Nearly half a million emergency department visits in 2009 were due to people misusing or abusing prescription painkillers.
  • Nonmedical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct healthcare costs.
Certain groups are more likely to abuse or overdose on prescription painkillers.
  • Many more men than women die of overdoses from prescription painkillers.
  • Middle-aged adults have the highest prescription painkiller overdose rates.
  • People in rural counties are nearly twice as likely to overdose on prescription painkillers as people in big cities.
  • Whites and American Indian or Alaska Natives are more likely to overdose on prescription painkillers.
  • About 1 in 10 American Indian or Alaska Natives aged 12 or older used prescription painkillers for nonmedical reasons in the past year, compared to 1 in 20 whites and 1 in 30 blacks.
The supply of prescription painkillers is larger than ever.
  • The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was 4 times larger in 2010 than in 1999.
  • Many states report problems with “pill mills,” where doctors prescribe large quantities of painkillers to people who don’t need them medically. Some people also obtain prescriptions from multiple prescribers by “doctor shopping.”
Some states have a bigger problem with prescription painkillers than others.
  • Prescription painkiller sales per person were more than 3 times higher in Florida, which has the highest rate, than in Illinois, which has the lowest.
  • In 2008/2009, nonmedical use of painkillers in the past year ranged from 1 in 12 people (age 12 or older) in Oklahoma to 1 in 30 in Nebraska.
  • States with higher sales per person and more nonmedical use of prescription painkillers tend to have more deaths from drug overdoses.

What Can Be Done

By the U.S. Government

  • Tracking prescription drug overdose trends to better understand the epidemic.
  • Educating healthcare providers and the public about prescription drug abuse and overdose.
  • Developing, evaluating, and promoting programs and policies shown to prevent and treat prescription drug abuse and overdose, while making sure patients have access to safe, effective pain treatment.

By the States

  • Start or improve prescription drug monitoring programs (PDMPs), which are electronic databases that track all prescriptions for painkillers in the state.
  • Use PDMP, Medicaid, and workers’ compensation data to identify improper prescribing of painkillers.
  • Set up programs for Medicaid, workers’ compensation programs, and state-run health plans that identify and address improper patient use of painkillers.
  • Pass, enforce and evaluate “pill mill,” doctor shopping, and other laws to reduce prescription painkiller abuse.
  • Encourage professional licensing boards to take action against inappropriate prescribing.
  • Increase access to substance abuse treatment.

By Individuals

  • Use prescription painkillers only as directed by a healthcare provider.
  • Make sure you are the only one to use your prescription painkillers. Not selling or sharing them with others helps prevent misuse and abuse.
  • Store prescription painkillers in a secure place and dispose of them properly.
  • Get help for substance abuse problems if needed (1 800 662 HELP).

By Health Insurers

  • Set up prescription claims review programs to identify and address improper prescribing and use of painkillers.
  • Increase coverage for other treatments to reduce pain, such as physical therapy, and for substance abuse treatment.

By Healthcare Providers

  • Follow guidelines for responsible prescribing, including
  • Screening and monitoring for substance abuse and mental health problems.
  • Prescribing painkillers only when other treatments have not been effective for pain.
  • Prescribing only the quantity of painkillers needed based on the expected length of pain.
  • Using patient-provider agreements and urine drug tests for people using prescription painkillers long-term.
  • Talking with patients about safely using, storing, and disposing of prescription painkillers.
  • Use PDMPs to identify patients who are improperly using prescription painkillers.

The epidemic of prescription drug overdoses in the United States has worsened over the last decade, and by 2008 drug overdose deaths (36,450) were approaching the number of deaths from motor vehicle crashes (39,973), the leading cause of injury death in the United States. Increasing trends in opioid pain reliever (OPR) sales has mirrored emergency room visits, drug treatment center visits, and deaths from overdoses. As a result of the prescription opioid overdose epidemic, as of March 22, 2016 the Food and Drug Administration requires a black box warning for all opioids that notes the serious risks of misuse, abuse, addiction, overdose, and death. For more on this, click here.

Given that 3% of physicians accounted for 62% of the OPR prescribed in one study (Swedlow et al., 2011), the proliferation of high-volume prescribers can have a large impact on OPR overdose death rates. Large increases in overdoses involving the types of drugs sold by illegitimate pain clinics (“pill mills”) have been reported. Such clinics provide OPR indiscriminately to large numbers of patients without adequate evaluation or followup. Sales data also did not include buprenorphine, an opioid primarily used for substance abuse treatment, though sometimes prescribed for pain. Its inclusion with drugs primarily used to treat pain would have inappropriately increased sales rates.

Public health interventions to reduce prescription drug overdose must strike a balance between reducing misuse and abuse and safeguarding legitimate access to treatment. To find this balance, healthcare providers should only use OPR in carefully screened and monitored patients when non-OPR treatments have not been sufficient to treat pain. States, as regulators of healthcare practice, have the responsibility and authority to monitor and correct inappropriate and illegal prescribing. Data from Medicare claims and from state prescription drug-monitoring programs, which collect records of prescription drugs prone to abuse from pharmacies, can be used to identify and address OPR misuse and abuse.

Listed below are the 12 recommendations released in March of 2016 by the CDC to serve as guidelines for primary care clinicians to use when prescribing opioids for chronic pain. The guidelines are grouped into three areas for consideration (see box below) and are followed by rationale for the recommendations and considerations for implementation. See this reference for full details.

 

CDC: 2016 Guidelines for Prescribing Opioids for Chronic Pain

Determining when to initiate or continue opioids for chronic pain

  1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
  2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
  3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

Opioid selection, dosage, duration, followup and discontinuation

  1. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting.
  2. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥MME/day.
  3. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
  4. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

Assessing risk and addressing harms of opioid use

  1. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages.
  2. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
  3. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
  4. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
  5. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

All interventions need to be evaluated further and new interventions developed. Concerted attempts to address this problem, especially in states with high rates of OPR sales, nonmedical use, or overdose mortality, might help control the epidemic.

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