It’s a fine line to walk … managing patients’ physical pain without exposing them to the pain of addiction. Making the balancing act even more difficult is the inability to tell which patients will use medications only as directed and which ones will escalate, sometimes surprisingly quickly, to drug abuse.
The face of drug addiction in Tennessee and across the United States has rapidly changed with images of the strung out, disheveled junkie being replaced by pictures of the quintessential soccer mom, established corporate executive or bright young college student.
A number of recent reports, including an annual assessment by the U.S. Drug Enforcement Agency (DEA), have found drug overdose deaths, driven largely by overdose from prescription opioids and the rise in heroin usage, have surpassed motor vehicle accidents and firearms as the leading cause of injury death in America. The report found 46,471 people died of drug overdoses in 2013 compared to 35,369 killed in car accidents and 33,636 killed by firearms.
The Federal Response
In February, the U.S. Food & Drug Administration called for a sweeping review of agency opioid policies in the face of a national epidemic. FDA Deputy Commissioner for Medical Products and Tobacco Robert Califf, MD, MACC, said the agency would take a number of steps to reassess its approach to opioid medications including convening an expert advisory committee before approving any new drug application that does not have abuse-deterrent properties. Additionally, he said the agency would work to expand access to and encourage development of abuse-deterrent formulations of opioid products, improve access to naloxone, and support better pain management options, including alternative treatments.
On March 15, the Centers for Disease Control and Prevention released new guidelines for prescribing opioids for chronic pain for patients 18 and older in the primary care setting. The guideline recommendations are specific to chronic pain outside of active cancer treatment, palliative and end-of-life care. In making the recommendations, the CDC noted healthcare providers wrote 259 million prescriptions for opioids in 2012, which is enough for every American adult to have a bottle of pain medication.
“More than 40 Americans die each day from prescription opioid overdoses; we must act now,” said CDC Director Tom Frieden, MD, MPH. “Overprescribing opioids — largely for chronic pain — is a key driver of America’s drug-overdose epidemic,” he continued, adding the guidelines will help physicians and patients make informed decisions about treatment.
In a teleconference announcing the guidelines, Frieden said the risks of using opioids far outweighs the benefits for most patients and noted safer alternatives exist.
The 12 recommendations focused on three areas of consideration:
- Determining when to initiate or continue opioids for chronic pain,
- Opioid selection, dosage, duration, follow-up and discontinuation, and
- Assessing the risk and addressing the harms of opioid use.
Key points include recognizing non-pharmacologic therapy and non-opioid therapy as preferred for chronic pain, establishing treatment goals with patients including realistic goals for pain and function, considering how opioid therapy will be discontinued if benefits do not outweigh risk, and engaging in ongoing discussions with patients about the known risks and realistic benefits of opioid therapy.
When starting opioid therapy, the recommendations call for prescribing at the lowest effective dosage, avoiding increasing dosage to ≥ 90 MME/day or carefully justifying that decision, prescribing immediate-release opioids instead of extended-release/long-acting opioids, prescribing for three days or less for acute pain and rarely more than seven days, evaluating benefits vs. harms within one to four weeks of starting opioid therapy or escalating dosage and continuing to evaluate every three months or more frequently.
To assess risk, the CDC calls for clinicians to review the patient’s history of controlled substance prescriptions and to check state databases before and during opioid therapy, to use urine drug testing before staring opioid therapy and consider using urine drug testing at least annually, to avoid prescribing pain medication and benzodiazepines concurrently whenever possible, and to offer or arrange for evidence-based treatment for patients with opioid use disorder.
Go online to NashvilleMedicalNews.com for links to the FDA announcement, CDC guideline recommendations, and CDC prescribing checklist.
The Problem in Tennessee
In February, the Tennessee Department of Mental Health & Substance Abuse Services (TDMHSAS) reported the state has seen a steady decline in prescription opioid drugs seizures according to data from the Tennessee Bureau of Investigation (TBI).
In 2012, there were 6,988 opioid seizures compared to 4,696 in 2014. The drop coincides with Tennessee’s Prescription for Success initiative, which launched in 2014. However, the law of unintended consequences might be in play as the state is seeing an increased appetite for heroin and painkiller replacement medication buprenorphine, which is now widely prescribed to ease opioid withdrawal symptoms and cravings and is known under the brand names of Subutex and Suboxone.
“It’s troubling to see these ‘so called’ painkiller replacement therapies dispensed by unlicensed clinics getting patients hooked and dependent on another drug, just as they were to prescription pain pills, “said TDMHSAS Commissioner Douglas Varney. “Our statewide, multi-agency Prescription for Success strategy did an excellent job of reducing demand for prescription pain opioid medications, but once again I’m very concerned about what’s emerging in our state.”
There were 82 heroin seizures by the TBI in 2009, rising to 341 in 2014. Similarly, the 437 buprenorphine seizures in 2009 had increased to 1,085 by 2014. While approximately half of Tennessee counties had buprenorphine seizures in 2011/2012, that number rose to nearly 70 percent of counties in 2014/15 with East and Middle Tennessee leading the way for rate of increase.
“There were very few heroin seizures by law enforcement in 2011 and 2012,” said Varney. “By 2015, seizures were occurring routinely in Tennessee’s larger cities and surrounding counties.”
While the numbers of opioid seizures were down, information released late last year from TDMHSAS showed prescription pain medicine remained the reigning ‘drug of choice’ across most age groups and illustrates the gap in seizures of illegally held opioids and the potential abuse of legally held prescribed drugs.
Reviewing two decades of state-funded substance abuse treatment admission data (1992-2012), the research highlighted a trend of prescription drug use across multiple age groups. “Prescription drug use increased among all the age groups we looked at, and jumped significantly among those in their 20s and 30s,” said Varney.
Based on the data, 59 percent of those aged 21-24 listed prescription drugs as their primary substance of abuse, and 49 percent of those aged 30-34 said the same. While alcohol remains the substance of primary abuse among those 50-54, the number citing prescription drugs was also on the rise.
“It’s very clear the addiction to prescription drugs continues to ravage Tennesseans of all ages with the greatest impact occurring among our young people in communities across the state,” said Varney. “We will continue to focus on strategies to reduce the supply and easy availability of prescription pain medicines, in cooperation with law enforcement and other Tennessee agencies. Additionally, we will ensure all Tennesseans have the opportunity to seek treatment and recovery for their addictions.”
RELATED LINKS:
FDA Calls for Sweeping Review of Opioid Policies
CDC Guidelines for Prescribing Opioids for Chronic Pain
