Is limiting or discontinuing opioid use in clinical care the answer to addressing the opioid epidemic?
If you take to heart current arguments about the best options to reduce opioid-related deaths and substance use disorders, one might conclude that the magic bullet is limiting, or even discontinuing, prescription opioid use in clinical care.
If only it were that easy.
In its zeal to stop the opioid-fueled drug epidemic from claiming more lives, the medical community—along with several state governments—have taken strident measures to reduce the flow of prescription opioids in clinical practice. In August, the DEA announced a significant reduction in opioid manufacturing for 2019.
Oregon, Michigan, Florida, and Tennessee, among other states, have passed laws restricting physicians' ability to prescribe opioids. Several health plans and health systems have implemented similar policies limiting prescribing of these medications.
The instinct to reduce access to a potentially dangerous substance is appropriate and commendable. I have no doubt that these measures will, over time, help reduce deaths and the prevalence of substance use disorders related to prescription opioids.
But as a pain management specialist, I also see the other side of this issue, which is the clinical problem of relieving pain when deprived of access to a potent form of treatment.
An estimated 25 million Americans live with daily chronic pain, according to the National Institutes of Health.1 Even when patients are treated for pain in the most comprehensive, systematic, and collaborative manner—including alternative cognitive and behavioral therapies—relief is often elusive. For many patients, opioids are not just an option, they are the only meaningful source of solace. This can be true even after all other pain-relieving measures have been applied.
The CDC recognized this concern when it implemented guidelines in 2016 for the prescribing of opioid pain medication for patients 18 years of age and older in primary care settings. The guidelines include recommendations about the appropriate prescribing of opioids to improve pain management and patient safety based on 3 guiding principles: preference to nonopioid therapy; starting with low-dose; short-term dosage (“start low, go slow”); and close monitoring of patients on opioid therapies.
The CDC guidelines also recognized laboratory screening as an important tool when treating patients for pain; they recommend urine laboratory screening before starting opioid therapy and then annually to assess for prescribed medications as well as other controlled prescriptions and illicit drugs.
Importantly, the CDC notes that, “Many Americans suffer from chronic pain. These patients deserve safe and effective pain management.” In fact, limiting access to opioids may unintentionally drive individuals with chronic pain to seek illicit and dangerous substitutes.
New CDC data back up the finding that some patients seek illicit or inappropriate drug relief when their access to opioid therapy is curtailed. The surging rates of deaths due to heroin and synthetic fentanyl— numbering nearly 30,000 in 2017, an increase of more than 9000 over 2016—underscore that use of non-controlled opioids is both prevalent and dangerous.
While many of these deaths involve people with entrenched substance use disorders, we can’t rule out the possibility that others involve people simply seeking relief after the medical community has failed them. I often see real patients with valid pain syndromes that admit to borrowing or buying opioids from diverted sources.
Quest Diagnostic’s experience aligns with these findings. According to our data, more than half of patients misuse their prescription medications, often by combining them with other drugs. The vast majority of the patients who receive clinical drug monitoring from Quest are receiving care from a primary care physician or pain specialist. While we do not know for sure, it is reasonable to assume that some of these risky behaviors emerge from efforts to alleviate pain.
Pain is one of the greatest healthcare challenges, and like many other areas of medicine it has no known cure. Fortunately, there are novel analgesics on the horizon with less or no abuse potential or associated respiratory depression. But until those medicines are available, healthcare providers must use all of the tools available, including opioids, to help alleviate pain. Tools such as drug monitoring can help reduce risks related to opioid misuse and substance use disorders. Let’s keep in mind that the suffering of our patients is real, and risks can be managed so that meaningful pain relief is within sight.