Charles E. Argoff, MD
Hi. I am Dr. Charles Argoff, Professor of Neurology and Director of the Comprehensive Pain Center at Albany Medical College and Albany Medical Center in Albany, New York. I would like to talk briefly about, although it is a huge topic, the near crisis (if not actual crisis) we face right now in grappling with the issue of opioid prescribing.
The Opioid Prescribing Crisis
Currently, and over many years, we have learned and appreciated that opioid analgesics (sometimes referred to, unfortunately, as "narcotics," but still opioid analgesics) can be a very effective component in treatment for individuals with moderate to severe pain. We often see the benefits in individuals who have acute pain and pain of a shorter duration that benefits from a short-term treatment with opioids. Where the crisis has emerged is: can we manage individuals safely on long-term opioids? And if so, how can we do so?
Unintentional Deaths From Using "As Prescribed"
Over the last few decades, the cancer pain community has showed us that there is a role for using opioids in pain management. We have been trying to learn the most effective way of using this class of medication in the treatment of chronic pain. Several issues have emerged: first, unfortunately, we have learned that as more opioids have been prescribed, we have seen almost a proportional increase in the number of unintentional deaths associated with use of those agents. There has been much clamor in terms of safety about the number of individuals who, even when they were supposedly taking their medication as prescribed, succumbed to the effects of the medications.
So we are not talking about people who are misusing, diverting, or obtaining multiple prescriptions. We are talking about patients who have been using their medications (to the best of anyone's ability to determine this) "as prescribed," but this medication use resulted in unintentional death.
Right now, it is one of the leading causes of death in certain age groups, and it is a huge problem. Why is it a huge problem? Obviously, it is a huge problem because death from the inappropriate use of medication is never acceptable and can be prevented. But even more so, it presents tremendous challenges not only to the pain specialists, the neurologists, and the anesthesiologists doing pain management, but also to every single prescriber in this country.
Safe Prescribing Tips
Opioids are an important class of medication used in the treatment of acute and chronic pain. We need to learn how to use these drugs as safely as possible. I'd like to highlight a couple of issues because opioids are effective for some but not all people, and they need to be used as safely as possible.
Individualize treatment. First, when you treat somebody with an opioid (and when you treat someone with any class of medication), keep in mind that it is a class of medication; it's not the be all and end all. There are people in whom opioids will either not be well tolerated or will not be effective alone. The expectation is not that you will say, "here's a prescription and that's all we're going to do for you." You need to individualize the treatment plan for each patient using opioids as a component.
If it's an expected duration of pain that is only going to be a few weeks, such as after a severe back sprain or other injury, then that patient should only be given enough medication to last that 2-week period. A return for follow-up should be arranged either in person or by phone so that you, as the prescriber, know what has happened to that person and whether that person needs additional treatment or additional evaluation.
Rational prescribing. All too often, children (adolescents) are getting prescriptions for hydrocodone/acetaminophen combinations after having their wisdom teeth extracted for 60 or 120 pills. Who would imagine that you would need a month's supply of this kind of medication for a simple tooth extraction? Yet this is happening. It happened in 2 circumstances that I am close to, including my own daughter when she had her wisdom teeth extracted. This is crazy; that's not exactly the best way to use an opioid. You should prescribe the smallest amount that the patient might need.
Get a diagnosis. If you are treating someone with acute or chronic pain, you need to have a diagnosis. What am I treating? As you are developing a treatment plan, which may or may not include opioids, you need to do the appropriate testing to evaluate that person. You also need to know if the person in front of you has a history of problems using opioids. That's not to say that you would never use opioids in a patient who may be problematic, but you certainly would use them with much greater monitoring. Keep in mind that unintentional deaths have occurred in people who have never been shown to have any issues.
Consider long-acting preparations. It's very important to consider: what type of opioid am I giving to this patient who is using it long-term? It cannot be said that longer duration of action or longer-acting opioids are superior with respect to pain relief, compared with shorter-acting opioids, but we can say that longer-acting opioids have fewer pills, a potential benefit of not having highs and lows in terms of blood levels, so they are not reinforcing potential addictive behaviors towards the medication and may be less problematic in trying to control someone's pain in a more stable manner.
Currently, many long-acting opioids have doses that are small enough that you can start the patient with a long-acting agent, as opposed to what has been taught in the past, which was that you should start patients on a short-acting regimen and switch them. It's much easier to get them on the right preparation as early as possible.
Multimodal therapy. Opioids are a class of medications that may be helpful for many, but not for all, patients with moderate to severe pain. When they are used, they should almost always be considered a part of a multidisciplinary or multimodal treatment for that person, especially in the treatment of chronic pain. Opioids are time-limited -- you need to monitor the patient's clinical response by seeing that patient, by following that patient, by finding out -- is the patient still using the medication? Should other treatments be considered? Is this person using the medication properly?
Opioid monitoring. This brings us to a point that I have not emphasized enough yet, which is monitoring the patient. Random urine drug screening may be important, even before you ever prescribe. If this patient tells you, "no, I don't use this, no, I've never used that," but you do a random drug screen before you prescribe and find that there happens to be opioid or cocaine metabolites or some other substance in the urine that the patient never told you about, obviously that's an important piece of history that you want to know before you prescribe to that person. Very often, people who are recreational drug users will not think that what they do is inappropriate, or they may just do it and not tell you what they do, and it's important to know to whom you're prescribing to maximize benefit and maximize safety.
Longer-acting opioids for chronic pain are preferred over shorter-acting opioids because of their ability to provide smoother, more stable blood levels of the medication. That may not necessarily improve pain relief, but it will be better for that person overall and is likely to be safer for that person.
Tamper-proof products. There are many new products, 2 of which are already available and others that are in development, that have significant enhancements in their ability to prevent crushing or changing the manner in which the drug can be used. Although that won't help everyone -- there are those who will just take a handful of pills at a time; it won't deter that kind of behavior -- it will help the person who has been crushing the medication for a use other than the medical purpose of an opioid. It will help that person not succumb to that behavior -- the less crushable the pill is, the harder it is for the drug to be misused in that form.
We really want to be able to have access to this class of medications. At the same time, an enormously important feature of prescribing opioids is prescribing them as safely and as rationally as possible.
Thank you very much.
From Medscape.com: Are Opioids Safe?
