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Writer's pictureFibonacciMD
Oct 9, 2019

Opioids, A Second Look

Challenging Conventions: Rethinking Opioid Prescribing in Chronic Pain Management

The scope of the opioid problem is immense. Taking a second look after attending an International Conference on Opioids.

InBrief

by Christopher King, NP


At the beginning of June 2019, I attended the International Conference on Opioids (ICOO) held at Harvard Medical School in Boston, Massachusetts. I believed that I was fairly well informed about the opioid crisis in this country, and I hoped to learn enough to give chronic-pain patients better rationales for denying opioid prescriptions. I was sure that information shared at the conference would support two important positions: some of these drugs often are not indicated for chronic pain, and overprescribing may have dire consequences. However, information shared during some of the presentations made me question the rigidity of my beliefs.


The scope of the problem is immense. From 1990-2012, opioid prescriptions in the United States increased from under 1 million to over 255 million. This is the equivalent of 81.3 opioid prescriptions for every 100 people living in this country. Although I was aware of more prescriptions being written after pain was considered “the fifth vital sign,” I found these numbers to be mind-boggling.


This spike in prescriptions may have resulted from the aggressive marketing of opioid pain medications by pharmaceutical companies, which certainly engaged in some predatory practices. However, they also offered a solution to a growing problem. One in five patients in the United States suffers from chronic pain, which causes some functional loss that may be quantified by quality-of-life measures ranging from ability to work to quality of sleep. Many of my patients have been prescribed opioids for years to manage chronic pain resulting from lower-back trauma, failed back surgeries, complex regional pain syndrome, contractures and spasms resulting from paralysis, arthritis, diabetic neuropathy, and many other causes.


Since 2011-2012, opioid prescriptions largely have been declining because of a national epidemic that has claimed tens of thousands of lives. In 2016, the US Centers for Disease Control and Prevention (CDC) released the CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016, which highlights a strategy to reduce excessive prescriptions. This guideline is a decent framework for the primary-care practitioner seeking to provide competent care for patients suffering from chronic pain. The most salient point for practitioners is to tread carefully when prescribing these drugs. Treating chronic pain without opioids is obviously the ideal; when this is not possible, risks must be weighed against benefits, and patients should be informed of the inherent risks of long-term opioid use. Unfortunately, the interpretation of this guideline has created some unintended consequences.


The major concern of these guidelines appears to advise prescribers to avoid any medication regimen that exceeds 90 morphine milligram equivalents (MME). It is common to see new patients trying to establish care after being discharged from another practice for failure to reduce their opioid dosage according to the CDC guidelines. Many patients who have been stable for years on their opioid dosage insist that a radical dose reduction will precipitate acute pain, withdrawal, and anxiety, with all having negative impacts on day-to-day living. The message in healthcare is clear—whereas practitioners hunker down to follow” standards of care,” real people who have built productive lives are destabilized by arbitrarily imposed limits imposed to mitigate only some risk.


The misapplication of the 90 MME became clear when I listened to a lecture by JeffreyFudin, PharmD, FCCP, FASHP, FFSMB, who addressed the problems in developing public policy when shared definitions of variables are lacking. MMEs are difficult to calculate for many drugs (eg, fentanyl, methadone). Dosages of these drugs cannot be reliably and consistently converted into morphine equivalents. Further, equianalgesic conversion calculators and tables are meant to help measure analgesic effect, nottoxicity. I had not considered this important point before this conference, and I began to see problems that had not occurred to me before. How can limited dosing to a target be recommended when those measurements are misapplied and misinterpreted with unreliable data?


In June 2019, the authors of the CDC guidelines published a statement in the New England Journal of Medicine acknowledging problems in how guidelines have been interpreted and applied. The statement refers to “the inflexible application” of the 90MME limit and the need for more research to determine how to best decrease high-dose opioids in patients given long-term treatment. Logically, a rapid decrease and/or discontinuation of these medications will cause deleterious physical effects and possibly precipitate abuse of other substances and/or other behaviors, thereby increasing the risk of morbidity and mortality.


Chronic pain remains one of the primary reasons Americans seek medical attention. Some 100-million Americans suffer from pain lasting over 3 months. Left inadequately treated, chronic pain may adversely affect multiple body functions, including the immune, endocrine, and cardiovascular systems. In addition, it may also impact depression, substance abuse, and suicide. These statistics are not as well documented as overdose deaths; in 2017, however, there were 47,173 suicide deaths and 17,029 deaths related to prescription opioid use. Reports from the US Food and Drug Administration have indicated that patients forced to taper down on medication doses or discontinue medications completely report “serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.” Healthcare professionals who treat chronic pain have been making this case to policymakers for some time, and the CDC’s recent statement published in the New England Journal of Medicine seems to corroborate these concerns.


Participating in the ICOO challenged me to think differently about safe opioid prescribing. In the past, I believed that eliminating opioid prescriptions for all indications except for palliative care and severe acute pain seemed reasonable. Unfortunately, this mindset fails to deal with the complex nature of the opioid crisis. Failure to adequately treat chronic pain has repercussions every bit as deadly and debilitating as the consequences of addiction. The CDC guidelines should not be applied as a standard of care. At the end of the day, I am a patient advocate and ally who strives to see my patients as individuals and treat them accordingly. It is still my goal to not over prescribe any medication. However, I realize that the opioid crisis is a very complex problem that may be successfully fought with a more thoughtful, nuanced approach.


ABOUT THE AUTHOR

Christopher King, NP

Christopher's nursing experience after undergrad was primarily working in Emergency medicine in Central and Coastal Maine. In 2014 Christopher went back to school for his Master's Degree and graduated in 2016 from the University of Southern Maine with his MSN. Currently, Christopher works for New England Sport and Spine in Manchester ME. When not working Christopher enjoys the Maine outdoors with his wife, children, and 2 dogs. 


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