Opioid use in the age of prescription abuse, misuse, diversion, and over-prescribing
In general, short-term opioid use is intended to relieve pain related to acute, traumatic injury, as well as post-surgical pain. However, the vast majority of opioids used in the United States are prescribed for chronic pain, with the goal of maximizing the functionality and quality of life of injured patients, while also controlling their persistent pain. The International Association for the Study of Pain has defined chronic pain as, “pain that persists beyond normal tissue healing time, which is assumed to be three months.”
Although the continuous use of opioids for chronic, non-cancerous pain is somewhat controversial, with reported benefits and detractors widely published in the medical literature, the reality of current medical practice in the United States clearly indicates that this use is increasingly common in the general and working population. Nevertheless, it is imperative to note that the purported efficacy of opioid treatment in cases of chronic, non-malignant pain is limited, and based mostly upon short-term studies. While every effort should be made to relieve discomfort, it is imperative that providers document an increase in physical functioning. In many cases, patients must accept the fact that it may be impossible to relieve all of their pain with opioids, while still maintaining all of their physical and mental facilities. We can most definitely relieve all pain; however, it is better known as anesthesia. That is not, and should not be the goal of functional pain relief with opioids.
There are a number of widely respected medical organizations that directly address the utility and pitfalls of chronic opioid use, including the American Pain Society (APS), The American Academy of Pain Medicine (AAPM), The British Pain Society, the Canadian National Opioid Use Guideline Group (NOUGG), and the American Society of Interventional Pain Physicians (ASIPP). Each group consistently agrees that short- and medium-term use of opioids for acute pain can be effective in the correct setting. In addition, they generally concur that evidence regarding the effectiveness of long-term opioid therapy is limited, and is very dependent upon a number of factors, including patient selection and active monitoring.
Although the science, efficacy, and safety of long-term narcotic use for the relief of chronic pain is a source of active debate in the medical community, each of the respective organizations previously listed recommends the following when considering the use of chronic opioid therapy for patients who have not attained maximum benefit from other interventions, such as non-opioid analgesics and physical therapy:
There is increasing evidence for the limited utility of high-dose, chronic narcotics. Although the definition of “high dose” varies by source, it is generally considered to be 100–120mg of morphine-equivalent dose. It is known that the occurrence of adverse outcomes and side effects increases dramatically in patients taking chronic “high-dose” opioids.
The interagency guideline issued by the state of Washington recommends that providers not prescribe more than an average daily morphine equivalent dose of 120mg without first obtaining a consultation with a pain-management expert, or having documented evidence of pain reduction. Typically, providers should prescribe chronic narcotics with the goal of attaining an as-low-as-reasonably-achievable dose that provides the desired therapeutic effect, while limiting adverse physical and psychological side effects. In addition, continuation of opioid therapy is indicated only if the case documentation shows meaningful improvement in pain, as well as patient functionality, i.e., if the patient’s pain does not lessen and their function improves, continuing chronic opioid therapy may not be warranted.
Beyond the general conditions noted above, it is also recommended that providers rotate medications to assist efficacy and discourage abuse, as well as maintain fastidious record keeping with documentation of functional improvement associated with continued use and escalation of therapy. It is also important to once again note that the medical community steadfastly encourages the use of additional modalities besides chronic opioids, in order to gain equal or improved patient outcomes, while resulting in lowered opioid doses and the avoidance of physical, psychological, and behavioral complications.
In an effort to discourage “doctor shopping”, and potential prescription medication abuse, numerous states have established mandatory statewide prescription drug monitoring programs (PDMPs) for controlled substances, which include: (1) collection of prescription data, (2) documentation of physician prescribing, and a (3) record of the dispensing pharmacy. Querying of a state PDMP should always be undertaken in conjunction with the self-reported documentation of medications utilized by the patient at each office visit. In states without a PDMP, providers should regularly request the patient’s medical notes from other providers, with the goal of verifying medication use history.
Although “pain management” is widely understood, and perhaps misunderstood to equal chronic opioid administration, there are a variety of concomitant and alterative therapies that may benefit patients with chronic pain. These alternative treatments include such modalities as non-opioid medications, therapeutic exercise regimens, physical therapy, interventional techniques, surgical interventions, and cognitive behavioral therapy. It is the rare patient who will only benefit from chronic, high-dose opioid monotherapy.
In most cases, the incorporation of FDA-approved treatment modalities besides, or in concert with chronic opioids, can stabilize, reduce, or possibly even eliminate the need for chronic opioids. When appropriately utilized and monitored, opioids can be “wonder” drugs that relieve pain and increase patient functionality; however, if utilized haphazardly, they can result in addiction and catastrophic patient outcomes. A team approach including the patient, provider, adjuster, and insurer all working for the benefit of the patient increases the likelihood of a successful outcome.
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Dr. James McCluskey is a Fellow at the American College of Occupational and Environmental Medicine. He is a board-certified occupational medicine physician, as well as a PhD-trained toxicologist. His medical practice primarily focuses on the evaluation of medical cases involving environmental/occupational chemical, respiratory, infectious and allergen exposures.
