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Prescription Opioid – Therapy or Epidemic?

Physician Connection

Winter 2013


Second in a series of articles about pain management issues and techniques.

By Calvin Chiang, MD

A recent paradigm shift has occurred regarding prescription opioid use, prompted by the potential and actual impact of these medications on patients and society as a whole.

Until recently, much of medical knowledge regarding opioids has been disseminated by pharmaceutical companies and consultants promoting the benefits and lack of risk. For example, drug-company-sponsored studies in the 1990s boasted addiction rates of 1%, while real-world rates of addiction and misuse are over 20%, possibly as high as 58%. A concept of “pseudo-addiction” was used to justify dosage increases in light of aberrant behavior. These experts declared opioids had no ceiling or maximum. Pain relief was the endpoint, and complications were minimized.

Pain and addiction specialists increasingly agree about the significant long-term risks of chronic opioid therapy (COT), which can include overdose, worsening of diabetes complications, immune system compromise, changes in humoral control, loss of functionality and gainful employment, depression, death in MVCs, physical dependence, tolerance and addiction. Many pain physicians advocate either a no-use policy or a ceiling of 100 MED a day for chronic nonmalignant pain; post-surgical and palliative situations are exceptions.

Additionally, state and national groups have declared an epidemic of opioid misuse. Over 14,800 deaths occurred in 2010 from opioid overdose, more than cocaine and heroin combined. These medications are also being diverted for nonmedical consumption: more than 12 million people used prescription opioids for non-medicinal purposes in 2010. An estimated 80% of opioids abused by teens – whose use has tripled – come from family and friends.

Increasingly, legislatures are acting to restrict opioid availability and reduce misuse. Last summer New York State ratified the Internet System to Prevent Over- Prescribing (I-STOP) law; other states, notably Florida, Oregon, and Washington, have enacted even stricter regulations. I-STOP mandated that hydrocodone containing products become Schedule II, and, like other opioids, are now limited to one-month scripts without refills. Tramadol-containing products, previously unscheduled, are now Schedule IV. Tramadol is thought to have low abuse potential; the parent compound has actions consistent with an SNRI, but it is hepatically demethylated into 0-desmethyltramadol, which has stronger centrally acting opioid effects.

Future expected legislative action includes the establishment of an online database and prescription mechanism whose access will be required for providers or their assistants, to review patients’ most recent Schedule drug prescriptions and criminal records, and prescribe medications electronically. This is aimed at reducing the “doctor shopping” that has exacerbated this serious problem.

This leads to a conundrum for many physicians. Patients remain vetted on the continued use of these medications. Well-meaning physicians are keenly focused on helping their patients, yet continuing prescriptions may not be appropriate. How does one proceed in this legal and ethical quagmire? At minimum, standard recommendations should be followed. My next column will explore this issue further.

Calvin Chiang, MD, is Medical Director of the RGHS Center for Pain Management.