Addiction Medicine and Relapse Prevention – Practical Pain Management by Jennifer Schneider, MD, PhD
The current state of opioid prescribing, addiction, and response in the United States – undated but most likely 2019
The State of Opioid Affairs
One of the most commonly discussed public health issues in the US today is the opioid overdose deaths crisis and how to solve it.
The “usual suspects” are clinicians who prescribe opioids, and the most commonly proposed solution is to decrease the number of opioid prescriptions.
One approach is regulatory: The CDC 2016 guidelines1 on prescribing opioids for chronic pain, aimed at primary care physicians, has been interpreted by many states as a requirement for all prescribers not to exceed between 60 and 120 mg morphine equivalents (MMEs) per day, depending on the state, with a major push to avoid going over 90 MMEs.
Another strategy is research focused: academic, for-profit, and nonprofit organizations alike are conducting studies on the benefits (or lack thereof) of opioids in managing chronic pain, as well as on the risks at stake when they are prescribed.
I found that the only studies that being funded lately are ones looking for “risks” of opioid use. To avoid mentioning any benefits, the patients’ pain and its relief from opioids are never considered, creating research with Opioids Blamed for Side-Effects of Chronic Pain.
An increasing number of published studies have concluded that opioids offer minimal benefits while carrying high risks of abuse [see link above], diversion, or addiction, thus supporting the [totally wrong] theory that the primary solution to the opioid crisis is to minimize prescribing.
Addiction is not the Usual Outcome of Opioid Use
The major assumption behind both efforts is that prescribers are turning most of their chronic pain patients into addicts, resulting in a large number of patients at risk of opioid overdose deaths
In reality, however, “addiction occurs in only a small percentage of persons who are exposed to opioids – even among those with pre-existing vulnerabilities,” as stated by Nora Volkow, director of the National Institute on Drug Abuse (NIDA), part of the NIH
Multiple publications support this conclusion. In a review of 67 studies of addiction following opioid use, Fishbain, et al,3 reported a risk of 3.27%.
A Cochrane review found a median incidence of 0.5% of de novo addiction, and a median prevalence of 4.5%.
They concluded that, “opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence” [ie, addiction or opioid use disorder].
Some of this confusion about risk of addiction results from the false belief that physical dependence, an expected consequence of chronic opioid use, is the same as addiction, currently termed Opioid Use Disorder (OUD)
This author explains the difference in a recent paper.
Another misunderstanding is that patients living with chronic pain are likely to develop a tolerance to the analgesic effect of opioids (and/or opioid-induced hyperalgesia) requiring an ever-increasing opioid dose.
Prescribers typically do find that patients may need a dose increase, however, the reality is that there are reasons for this unrelated to tolerance, including the following:
- An opioid is initially prescribed in low dose in order to assess resulting nausea and sedation, and then increased if necessary for adequate analgesia.
- When an effective dose is reached, the patient is then likely (as is hoped!) to increase his or her activity, with the result that another dose increase may be necessary in order to maintain the improved function.
- When a dose becomes less effective after some months, depending on the source of pain, it may well be a consequence of disease progression. (Read more on OIH).
It’s that last point that seems so obvious but apparently is not.
Whatever chronic conditions we suffer, the process of aging worsens it. Doctors should know this but they seem to forget – at least until they themselves suffer some aches and pains that inevitably arise even from “healthy” aging.
Other Approaches Are Needed
Since 2010, the quantity of prescribed opioids in the US has consistently decreased while the number of opioid overdose deaths has continued to increase.
The simultaneous decrease in prescription opioids and increase in opioid overdose deaths is so counterintuitive that it clearly mandates consideration of other approaches to solve this crisis
Obviously the words “clearly mandated” don’t mean much to the anti-opioid zealots. They just encourage us to keep doing more and more of what does not work hoping that eventually, the outcomes will be different.
This is the definition of insanity, according to what they tell addicts all the time: “doing the same thing over and over and expecting different results is the definition of insanity.“
A crucial part of the process is to understand
- which opioids are responsible for opioid deaths and
- which groups of people are taking these drugs.
In reality, the statistics tend to combine several different groups, including:
- those who purchase prescription drugs on the street to treat their anxiety, depression, PTSD, etc.
- those who purchase prescription drugs on the street to experience a high and feed their addiction
- those whose source was a bottle of prescription opioids found in a relative or friend’s home or who were given these drugs by a friend or relative
- those who purchased illegal drugs, such as heroin or illegal fentanyl, for the same reasons as those listed above
- those who accidentally took too many prescribed pills and overdosed
- those desperate individuals whose goal was to commit suicide.
Combining all these different categories was necessary to create the huge numbers that sparked the panic about “heroin pills” and created the supposed “opioid crisis”.
Separating overdoses from prescribed versus illegal drugs, the data show that the overwhelming source of increased overdose deaths is tied to illegal drugs.
It is well documented that opioids (especially immediate-release opioids) may be an effective psychotropic treatment for depression, anxiety, and PTSD.
These medications seem like miracles for people who are suffering from constant high-impact pain.
It is further likely that many patients with psychological problems who are prescribed opioids for pain find that opioids also effectively treat their mental health conditions; thus, they may become reluctant to discontinue using such medications.
These patients are not addicts but rather patients in need of behavioral health evaluation and treatment.
Framing the Discussion
Unfortunately, insurance companies are increasingly unwilling to pay for modalities other than medications and procedures.
However, they will pay for various extremely dangerous invasive treatments, like epidural injections and spinal fusions that can and do easily go wrong and cause even more pain.
Principal Deputy Commissioner of the FDA, described the consequences of this approach just last year:
“At a time when most insurers still do not provide adequate reimbursement for nonpharmaceutical approaches to pain or treatment for opioid use disorder [ie, addiction], overly restrictive prescribing policies risk pushing patients with pain or addiction to illicit drugs, a transition many have made.”
In this PainScan on Addiction Medicine & Relapse Prevention, recently published papers will be reviewed in the coming months in an effort to help parse out the conclusions that advance the field from those that support preconceptions about the value and risks of opioid prescribing.
Jennifer P. Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management, Tucson, AZ
Frank A. Kunkel, MD
Clinical Associate Professor, Anesthesiology / Chief Medical Officer, Accessible Recovery Services, Pittsburgh, PA
8 Articles in this Series:
The Krebs SPACE Trial – 2018;319(9):872-882.
Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid and abuse – 2019;179(2):145-152
The influence of anxiety sensitivity on opioid use disorder treatment outcomes. – 2019;27(1):64-77.
Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations – 2018; (Dec); Available at: http://www.hhs.gov/ash/:advisory-committees/pain/reports/index.html
The Addiction Patient – 2019;Commentary:
What the SUPPORT Act Means for Providers – 2018;Public Law 115-217:H.R.6
Inside the NCASA Report: Ending the Opioid Crisis – 2017;centeronaddiction.org/addiction-research/reports:
The role of opioid prescription in incident opioid abuse and dependence among individuals which chronic non-cancer pain – 2014;30(7):557-564