VOLUME 36, ISSUE 2

Reports of the danger of opioid painkillers and their propensity to lead to addiction and overdose have recently been ubiquitous in both medical literature and popular media sources. This awareness has led to a series of reforms coming both from within healthcare systems and written into law by state legislatures. While action is an imperative given the grave nature of this epidemic, a compassionate response is owed to the patients who are caught in the middle of this struggle. Restricting access to opioids does little to solve the problems of those who have developed physiologic dependence while receiving these medications from a legitimate source, and ignoring their predicament risks causing unnecessary withdrawal symptoms and potentially pushing some towards illicit markets, thereby further fueling the epidemic that we seek to treat.

Any casual observer of the medical literature is, at this point, familiar with the story of the opioid epidemic in America. The American prescription and consumption of opioids dwarfs that of other countries, with America prescribing approximately 60% more per capita than the next leading country.¹ Over the past two decades the Centers for Disease Control and Prevention (CDC) data has shown an exponential increase in overdose deaths from opioids, undoubtedly in part as a consequence of increasing prescription rates². This practice initially grew out of a movement in the 1990’s to better acknowledge and treat patients’ pain and, through a variety of factors, opioids subsequently became a mainstay in both acute and chronic pain treatment, followed by the ensuing overdose epidemic described above. As most healthcare providers are acutely aware, chronic pain is notoriously difficult to treat. While opioids are undoubtedly powerful analgesic agents that are very effective for palliative care and post-operative pain, their efficacy in treating chronic non-cancer pain is much less clear. There have been relatively few long-term comparative trials to study the effectiveness of opioids in chronic pain, and a recently published randomized clinical trial showed no significant difference in pain severity and pain-related function between opioid therapy and therapy with acetaminophen or non-steroidal anti-inflammatory drugs.³ As a country, we have collectively witnessed the potential for abuse and addiction associated with opioid use that has yet to reach a peak, as opioid related deaths continue to climb with each successive year. Intertwined with the crisis of medically prescribed opioids stands a synchronously growing heroin epidemic feeding off of addiction and desperation. Both epidemiological data and anecdotal evidence from surveys indicate that many individuals in the throes of heroin addiction got their start with medically prescribed opioids.^{4, 5}

Although the response to this crisis was initially slow, the last few years have seen a cascade of new legislation and medical board rules aimed at curbing this deadly tide. Many current strategies focus on restricting the prescription of opioids and increasing documentation by providers of education efforts and risk assessment tools. Another popular strategy has been to increase availability of the overdose reversal agent naloxone. In Texas, recently enacted law changes have placed a series of requirements on physicians prescribing controlled substances to patients with chronic pain, including baseline drug testing, use of the state prescription database, and a signed pain management contract for the patient. Similarly, Michigan, Florida, and Tennessee have recently set limits on the quantity of opioids allowed to be prescribed at one time. On a federal level, the DEA has increased oversight and control of some medications by changing their scheduling protocols. Federal funds have also been allocated to help combat the opioid epidemic nationwide with an extra $3.3 billion appropriated by congress for research, prevention, and management of the opioid crisis. The CDC reports an 18% decrease in the amount of opioids prescribed between 2012 and 2016, thought to be largely due to increased regulations and increased awareness through media outlets.

These new changes have adversely affected many patients who were previously maintained on long term opioid therapy for chronic pain who now have difficulty finding providers who will maintain their opioid regimen. It is important here to make a distinction between these patients and those who would be diagnosed with opioid use disorder by DSM criteria. While those with a defined use disorder often show patterns of increasing use and exhibit social dysfunction as a result of their use, many patients were led to high dose opioid use by medical advice and find themselves in a condition of physical dependence without the accompanying psychosocial dysfunction which characterizes abuse. Although better understanding and treatment of chronic pain would help immensely, progress in this field has been slow and allowing these patients to go untreated in the meantime is an untenable solution.

We would urge the medical community to acknowledge the plight of these patients and to search for a reasonable and compassionate response. They are at risk of becoming casualties caught in the middle of the opioid crisis if cut off from their regular opioid supply due to new restrictive regulatory burdens placed upon physicians. If providers are not comfortable with the continuation of opioid therapy, then either a gradual taper accompanied by a thorough discussion of alternative pain management strategies or transition to another prescribing provider is necessary. Patients abruptly cut off without appropriate intervention will not only undergo distressing withdrawal symptoms, but are also at high risk of turning to the illicit market, as so many who initially started on medically prescribed opioids already have. In this marketplace they are much more likely to succumb to the overdose crisis as dosages are not medically controlled and street heroin is often cut with highly potent fentanyl. A morally accountable response requires the healthcare community to treat these patients as victims rather the perpetrators of the crisis, and to ensure that they are adequately cared for while exploring non-opioid alternatives. The reputation of the medical community and the trust of our patients are at stake as we respond to this crisis and, if lost, will not be easily recovered.

As is so often the case, more information and better evidence will be our best tools in addressing this problem. Studies exploring effective management of chronic pain as well as studies on both intended and unintended effects of recent legislative efforts will be most helpful in allowing us to effectively reduce opioid overdose deaths while simultaneously minimizing the fallout for the many patients taking opioids responsibly. Tools such as prescription drug databases and pain contracts can be very helpful but must be implemented in such a way that the regulatory burden does not dissuade providers from prescribing opioids entirely. Rather than simply restricting access, it is important to utilize harm reduction strategies, such as expanding access to naloxone and implementing Good Samaritan laws, both of which have been associated with decreased rates of overdose.⁶ A dialogue between legislative bodies and the medical community is crucial to ensuring that the response is effective for both patients and providers alike. As the opioid epidemic has become a complex problem, our response will be most effective and well-received if we combine evidenced based decision making with compassion and empathy for our patients.

The above authors have no conflicts of interest to declare.

1. International Narcotics Control Board. Narcotic Drugs – Vienna, Austria, 2017. United Nations Publications. https://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2017/Narcotic_drugs_technical_publication_2017.pdf Last accessed August 14, 2018
2. Centers for Disease Control and Prevention. Annual Surveillance Report of Drug Related Risks and Outcomes — United States, 2017. Surveillance Special Report 1. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. https://www.cdc.gov/drugoverdose/pdf/pubs/2017cdc-drug-surveillance-report.pdf Published August 31, 2017. Last accessed August 13, 2018
3. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis PainThe SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872–882.
4. Sarah G. Mars, Philippe Bourgois, George Karandinos, Fernando Montero, Daniel Ciccarone, “Every ‘Never’ I Ever Said Came True”: Transitions from opioid pills to heroin injecting, International Journal of Drug Policy,Volume 25, Issue 2, 2014, Pages 257-266.
5. Muhuri PK, Gfroerer JC, Davies MC; Substance Abuse and Mental Health Services Administration. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review. http://www.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf. Published August 2013. Last accessed August 30th, 2018.
6. Chandler McClellan, Barrot H. Lambdin, Mir M. Ali, Ryan Mutter, Corey S. Davis, Eliza Wheeler, Michael Pemberton, Alex H. Kral, Opioid-overdose laws association with opioid use and overdose mortality, Addictive Behaviors, Volume 86, 2018, Pages 90-9.5