Changing Opioid “Quick Fix” Pain Management

Opioids on a table.
by admin
August 2, 2017 Military & Veteran Health

According to the American Society of Addiction Medicine (ASAM), drug overdose is the leading cause of accidental death in the United States with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic with 20,101 deaths from overdose related to prescription pain medication and 12,990 overdose deaths related to heroin. From 1999 to 2008, prescription pain reliever sales, substance abuse disorder treatment admissions and overdose death rates increased in parallel. Sales of prescription pain relievers in 2010 were four times those in 1999; substance abuse disorder treatment admission rates in 2009 were six times that of 1999, and overdose death rates in 2008 were four times the 1999 rate.

Additional ASAM statistics include:

  • In 2012, 259 million prescriptions were written for opioids, which is enough to give every American adult their own bottle of pills;
  • Four in five new heroin users began by misusing prescription painkillers; and
  • Ninety-four percent of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.”

Center to this crisis is a 2016 Washington Post-Kaiser Foundation survey, which found that nearly all long-term users of prescription painkillers say they started with a prescription from a doctor. Majorities say their doctor talked to them about the possibility of addiction or dependence and other ways to manage pain, but 61 percent say there was no discussion about a plan for getting off the painkillers. When asked about a number of efforts that would be effective in reducing abuse of prescription painkillers, long-term users point to efforts like increasing pain management training for medical students and doctors (82 percent) and increasing research about pain and pain management (81 percent).

In addition, according to the University of Pennsylvania’s Center for Ethics and Rule of Law (CERL) 2017 report, The Intersection of Opioid Overuse and Veteran Mental Health Challenges: “As of March 2015, the U.S. Department of Veterans Affairs (VA) reported that approximately 60 percent of military personnel returning from deployments in the Middle East and 50 percent of older veterans from previous deployments suffered from chronic pain nationwide. These rates exceed the reported 30 percent national average of chronic pain within the general American population.”

Margaret Danilovich, PT, DPT, PhD and instructor at Northwestern University’s Feinberg School of Medicine, Department of Physical Therapy and Human Movement Sciences, explains that almost 20 percent of health care visits are related to musculoskeletal problems like back pain, arthritis and neck discomfort. Yet, primary care physicians are not optimally trained to care for patients with such problems. Only 20 percent of medical schools have a mandatory musculoskeletal clerkship and less than one-half have a required musculoskeletal course.

According to Danilovich, to reduce use of opioids to manage pain, people should have greater access to physical therapists. She says physical therapists are healthcare providers with specific training in musculoskeletal conditions, which means they are skilled at identifying, diagnosing and treating movement problems, including those accompanied by pain. Danilovich points to a recent study that found only 10 percent of patients with low back pain who visited a primary care physician between 1997 and 2010 were referred to a physical therapist. Meanwhile, during this same period, prescription rates for opioids rose at an alarming rate – from 15 to 45 percent.

Despite CDC’s recommendation of physical therapy for treatment of chronic pain, lack of physician referral prevents patients accessing timely and effective physical therapy care. Danilovich argues that “focus on the immediacy of prescription pain relief rather than long-term pain management strategies not involving medication has led us down a dangerous path, medically and culturally.”

“We can remove these barriers to care and start to lessen our ‘quick fix’ thinking by removing the physician referral mandate,” she explains. “Allowing people to enter the healthcare system directly by seeing a physical therapist without a physician referral will provide patients effective care without delay.”

In support of systemic change, in March 2017 CDC took a step toward addressing the epidemic when it issued guidelines for the prescription of opioids for chronic pain. It is the first of its kind on a national level. The main findings of this updated review are consistent with the findings of the 2014 Agency for Healthcare Research and Quality (AHRQ) report. In summary, guidelines state the following: “Evidence of long-term opioid therapy for chronic pain outside of end-of-life care remains limited, with insufficient evidence to determine long-term benefits versus no opioid therapy, though evidence suggests risk for serious harms that appears to be dose-dependent.

“These findings supplement findings from a previous review of the effectiveness of opioids for adults with chronic non-cancer pain. In this previous review, based on randomized trials predominantly ≤12 weeks in duration, opioids were found to be moderately effective for pain relief, with small benefits for functional outcomes; although estimates vary, based on uncontrolled studies, a high percentage of patients discontinued long-term opioid use because of lack of efficacy and because of adverse events.”

CERL’s 2017 report also recommends that opioid prescribing patterns be carefully constrained and overseen. This is due to the risk of addiction and accidental overdose as well as the “very real” risk of death even when taken at prescribed doses, especially for veteran populations. Findings indicate that veterans are twice as likely to become addicted to opioids compared to members of the general population. According to a 2011 study commissioned by the National Institutes of Health (NIH), between 2010 and 2015 the number of veterans addicted to opioids rose 55 percent to a total of roughly 68,000. This figure represents about 13 percent of all veterans currently prescribed opioids.

As a result, CERL’s report includes the following veteran-focused recommendations regarding the intersection of current over-use and over prescription of opioids: (1) Opioid prescribing patterns and opioid use should be mandatorily restricted and time delimited, either by FDA mandatory action or by federal legislation, along the lines of the emerging state legislation in this area, and (2) extreme caution should be mandated in prescribing opioids for use in vulnerable populations, of which veterans may represent the highest risk category in view of combat trauma and other forms of psychological injury.

 

References:

  1. Opioid Addiction 2016 Facts & Figures, American Society of Addiction Medicine. https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf
  2. Margaret Danilovich.The simple solution to fight the opioid epidemic,” The Hill, May 7, 2017.

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