Opiates have been used for thousands of years as an analgesic, representing a new class of pain relief that was extremely powerful, but also highly addictive. By the 1830s, drug dependency reached disturbing proportions, leading to the mobilization of British warships along the Chinese coast to suppress opium traffic.
In the 1970s, doctors believed they were under-treating pain, and new opioids entered the market. The spike in prescriptions for painkillers was heavily endorsed by pharmaceutical companies, which had helped fund the studies that showed that doctors were under-prescribing pain medications.
From 2000 to today, the death rate from drug overdoses in the U.S. increased 137 percent, including a 200 percent increase in the rate of overdose deaths involving opioid pain relievers and heroin.
Unfortunately, risk-stratification tools do not allow clinicians to predict accurately whether a patient will become addicted to opioids, although those with a history of mental illness or addiction are at higher risk.
An observational case–control study of patients undergoing orthopedic surgery showed that those receiving long-term opioid therapy had significantly higher levels of preoperative hyperalgesia. After surgery, patients who had received long-term opioid therapy reported higher pain intensity (7.6 vs. 5.5, out of 10) in the recovery room than patients who had not been taking opioids.
While the benefits of opioids for chronic pain remain unclear, the risks of addiction and overdose are obvious. Partial agonists, such as buprenorphine, may carry a lower risk of dependence, but prescription opioids that are full mu-opioid–receptor agonists — nearly all the products on the market — are as addictive as heroin.
There are no firm guidelines for prescribing opioids after surgery. The CDC did release opioid-prescribing guidelines for chronic pain in 2016, but only included brief references to acute pain.
Because surgeons are often at the front lines in prescribing for pain, they must balance a growing epidemic versus pain management as a key factor in patient satisfaction scores that are tied to reimbursement rates. This requires the development of a comprehensive opioid prescription risk management plan to address the misuse and abuse of opioids.
Risk Management Plan
An effective prescription risk management plan must begin with these key areas: 1) population surveillance, including dosage, elevated risk, signs of overprescribing, and length of prescription; 2) clinician education; and 3) drug testing.
These strategies are critical for building effective and safe prescribing practices that minimize patient harm and associated liabilities.
Dosage — Surveillance of a patient population, whether it’s managed care, state Medicaid or a Medicare program, should focus on opioid outcomes and identify people who are taking opioids, whether appropriate or not. The use of any opioid can lead to overdose, but research shows that exposure to a higher dose of all opioids increases the risk of overdose.
Opioid doses of more than 100 morphine milligram equivalents (MME) are disproportionately associated with overdose-related hospital admissions and deaths. The use of long-acting opioids, such as methadone and oxycodone, has also been associated with an increased risk of overdose.
At the same time, higher dosages have not been shown to reduce pain in the long term. One randomized trial found no difference in pain or function between a more liberal opioid dose escalation strategy (with average final dosage 52 MME) and maintenance of current dosage (average final dosage 40 MME).
Elevated Risk — Several identifiable characteristics among patients have been reliably associated with an elevated risk of opioid overdose. Factors include:
• history of overdose
• history of addiction to any substance, especially alcohol, benzodiazepines or opioids
• health problems associated with respiratory depression or concurrent prescription of any medication that has a depressive effect on the respiratory system, such as benzodiazepines and sedative hypnotics
• history of suicidal thoughts or attempts
• diagnosis of major depression
Recommended mitigation strategies include an overdose risk assessment and urine drug screening before prescription or re-prescription of opioids to verify absence of drugs of abuse.
Overprescribing — Overprescribing of opioids is thought to be a major contributor to the opioid epidemic, with two-thirds of opioid misuse being attributed to opioids obtained through a single physician.
Overprescribing enables opioid diversion and increases the potential for addiction. Surgical patients are nearly four times more likely to get post-discharge opioids than their non-surgical counterparts. Orthopedic surgeons alone were responsible for 7.7 percent of opioid prescriptions in 2009.
Despite these numbers, surgeons have yet to find the right balance of opioid prescriptions: between 3-10 percent of opioid-naive patients become chronic users, and 80 percent of prescribed pills in the remaining group of patients are unused.
The lack of guidance around postsurgical opioid prescribing stems in part from lack of understanding about the effect of longer and larger regimens of post-discharge opioids.
In its Star Ratings, CMS screens for the use of opioids from multiple providers and pharmacies or at high dosage in people -— without cancer and not in hospice care -— as part of their opioid overutilization measure. A patient being prescribed morphine, for instance, from four different providers and four different pharmacies will be flagged at the claims level, integrating the medical and provider component.
Length of Prescription — According to one study, the duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. The analysis quantifies the association of prescribing choices on opioid misuse and identifies levers for possible impact.
Education of clinicians at all levels about safe opioid use is critical for reducing risks associated with abuse levels. Topics to focus on include pain assessment and management, and the importance of educating patients about the risks associated with opioids, such as physical dependence and addiction.
Education can empower clinicians to make appropriate, well-informed decisions about whether to initiate, continue, modify, or discontinue opioid treatment for each individual patient at each clinical encounter. Education is vitally important for both reducing overprescribing and ensuring that patients in need retain access to opioids.
Physicians who prescribe opioids must understand a wide range of problems, including addiction and drug-drug interactions, safe dosing, how to transition from one medication to another, how to monitor and look for signs of abuse, and how to use a state prescription monitoring program.
Drug testing gives clinicians actionable information to use in conversations with patients about how and when they are taking their medications. Clinical guidelines for opioid therapy recommend that clinicians perform drug monitoring tests in conjunction with other checks, such as pill counts, self-reporting and behavior monitoring. Testing can provide evidence that patients are remaining compliant with treatment.
It’s important to seek a highly reputable drug testing facility that offers fast, accurate, high-quality laboratory and genomic testing, and serves as a collaborator with providers by providing an extensive range of testing services, including specialized diagnosis, screening, and evaluation.
Scott Howell is an acclaimed physician with over 25 years of clinical experience in medicine, public health and addiction. He continues to practice at Kaiser Permanente Los Angeles Medical Center’s Department of Addiction Medicine.
Main image credit: Associated Press