Provider Communicator Summer 2018
This is a newsletter article. The information may not be up-to-date. If you have questions, please contact your Provider Coordinator.

How did we get here and what do we do now?

Jeremy Fejfar, PharmD

The CDC estimates that drug overdoses are now responsible for 66,000 deaths annually, which is more than three times what it was nearly 20 years ago. Overdose is now the leading cause of death for those under 50.

Between 21 to 29 percent of patients prescribed opioids for chronic pain misuse them,¹ with eight to 12 percent developing opioid use disorder.⁸ In fact, four to six percent of those who misuse prescription opioids transition to heroin2-3 and 80 percent of heroin users first misused prescription opioids.³

These are sobering statistics and should cause all of us to take a moment to reflect on how we arrived here, and what we can do individually to reverse this trend. It’s going to take action at the legislative level to fund novel approaches to address the underlying causes that lead people to turn to drugs, and to find effective and compassionate ways to assist those who are using illicit substances. Television commercials and prison sentences will not remedy this situation; these have been our weapons in the war on drugs for decades, and they have already failed to keep this epidemic at bay.

However, we cannot rely solely on legislators to lead us out of this situation. As medical professionals, we must acknowledge our role in how we got here and the power we hold to change practices. It is true that certain individuals and pharmaceutical companies misled providers about the risk of addiction with opioids. In the 1990s, Purdue funded thousands of pain-related educational programs which encouraged the long-term use of opioids for chronic non-cancer pain.⁴ They claimed that opioids had a low risk of addiction (“less than 1%”), a claim that was not supported by an analysis they cited (which was looking at iatrogenic addiction when used for acute pain, not when opioids are used daily for a prolonged period for chronic pain).12 As part of this campaign, Purdue provided financial support to the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, the Joint Commission, pain patient groups and other organizations. Consequently, we saw these groups all advocate for more aggressive identification and treatment of pain.

Even though there is no high-quality evidence that supports opioid therapy longer than six months, we now have millions of Americans using opioids chronically. This is especially significant in considering a recent study published in JAMA.⁵ In this study, patients with moderate to severe back pain or hip / knee osteoarthritis were randomized to receive either opioid or nonopioid therapy, and their pain-related function was evaluated over a 12-month period. The groups did not differ significantly on pain-related function over 12 months, finding that opioids did not demonstrate an advantage over nonopioids (acetaminophen, NSAIDs, TCAs, duloxetine, pregabalin and topical analgesics). Further, only 41 percent of patients receiving opioids showed a reduction in pain of at least 30 percent from baseline, whereas in the nonopioid group, 54 percent of patients experienced this level of reduction. The opioid group also experienced more side effects than the comparator group. This study concluded that opioids did not demonstrate any advantage over nonopioids that could outweigh their greater risk of harms.

For neuropathic pain, evidence suggests that opioids do not fare any better. According to an article in Pain Medicine,⁶ compared with patients taking any dose of opioid, patients not taking opioids had statistically lower disability and higher physical functioning scores (after adjusting for disease severity).

Even in acute situations, opioids may not always be superior to nonopioids. A 2017 article concerning a study comparing oral morphine to oral ibuprofen administered at home to children for postoperative orthopedic pain showed that both interventions decreased pain scores similarly, with no statistically significant differences in pain relief.⁷ The same year, a different study published in JAMA showed the same noninferiority between opioids and nonopioids (ibuprofen plus acetaminophen) for the treatment of acute extremity pain in adults in the emergency department.⁸

Quartz is implementing an Opioid Risk Management Program beginning on August 1st.  Learn more.

When opioids are determined to be necessary for the treatment of acute pain, they are often over-prescribed for this as well. Studies have shown that patients often have leftover opioids following these prescriptions.  One review of seven studies showed that 67 to 92 percent of patients reported unused opioids,⁹ and other information indicates that these leftover medications often end up illegally diverted to other individuals.10

Guidelines released in 2016 by the Centers for Disease Control (CDC) state three days or fewer of opioid supply “will often be sufficient” for acute pain and supplies for more than seven days “will rarely be needed.” The guidelines further indicate that patients should be prescribed the lowest effective dose. Clinicians should reassess individual benefits and risks when increasing dosage to >50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to >90 MME / day (unless this decision is carefully justified).11 They also caution about the use of opioids and benzodiazepines together as this combination triples the mortality rate.

Providers are well aware of the availability of acetaminophen (APAP) and the many different NSAIDs, however, rarely are patients told to use them together. Combining these two different analgesics amplifies the pain relief that can be achieved. Further, establishing the expectation that this combination is going to relieve pain increases the likelihood of success.13 Studies that measured the percent of patients achieving a >50 percent pain reduction for six hours showed that while oxycodone 5mg achieved this in 23 percent of patients,14 ibuprofen (400mg) plus APAP (1000mg) was successful in 73 percent of patients.15

Beyond NSAIDs and APAP, there are many other nonopioid treatment options to consider. Tricyclic antidepressants (nortriptyline, amitriptyline, etc.) and duloxetine (Cymbalta®) are indicated for various types of pain, as are gabapentin and pregabalin (Lyrica®). Also, many topical treatments are now available and quite affordable. Diclofenac 1% gel (Voltaren® Gel) may be warranted when oral NSAIDs cause side effects. Lidocaine cream is available OTC in various forms (Aspercreme® 4% cream, Aspercreme® 4% patch, etc.), and others include lidocaine with additional ingredients, such as menthol (IcyHot® cream, IcyHot® patch, etc.). There are various electrotherapy and TENS units available without a prescription in major retailers and online, as well.

To support clinicians in tapering opioids, the CDC offers a mobile app, a pocket guide and online training with motivational interviewing components.  Access CDC resources here.  

The causes of the current opioid epidemic are multifactorial, and a solution remains elusive. However, given the role that healthcare practitioners play in combating this problem, we must jettison outdated beliefs concerning the risks and benefits of opioid therapy and carefully consider the necessity of each prescription and every dose of narcotic that is prescribed.

  1. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1.
  2. Carlson RG, Nahhas RW, Martins SS, Daniulaityte R. Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug Alcohol Depend. 2016;160:127-134. doi:10.1016/j.drugalcdep.2015.12.026.
  3. Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Rev. August 2013.
  4. Accessed 5/17/2018.
  5. Erin E. Krebs, MD, MPH1,2; Amy Gravely, MA1; Sean Nugent, BA1; et al, “Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain.” JAMA. 2018; 319(9):872-882
  6. Bostick GP, et al. Pain Medicine 2015; 16:1361-1368
  7. Naveen Poonai MD, Natasha Datoo MD, Samina Ali MDCM, et al, “Oral morphine versus ibuprofen administered at home for postoperative orthopedic pain in children: a randomized controlled trial.” CMAJ 2017 October 10; 189:E1252-8. doi:10.1503/cmaj.170017
  8. Andrew Chang, MD, Polly Bijur, PhD, David Esses, MD, et al, “Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial.” JAMA 2017; 318(17): 1661-1667. doi:10.1001/jama.2017.16190
  9. Mark Bicket, MD, Jane Long, BS, Peter Pronovost, MD, et al, “Prescription opioid analgesics commonly unused after surgery.” JAMA Surg. doi:10.1001/jamasurg.2017.0831
  10. Eleanor Lewis PhD, Michael Cucciare, PhD, Jodie Trafton, PhD, “What do patients do with unused opioid medications?” Clin J Pain 2014; 30:654-662
  11. Deborah Dowell MD, Tamara Haegerich PhD, Roger Chou MD, “CDC guideline for prescribing opioids for chronic pain- United States, 2016” MMWR Recomm Rep 2016;65(No.1)
  12. Porter J, Jick H. “Addiction rare in patients treated with narcotics.” N Engl J Med. 1980 Jan 10;302(2):123
  13. Kam-Hensen S, et al. Labeling of medication and placebo alters the outcome of episodic migraine attacks. SCI Transl Med 2014.
  14. Derry S, et al. Single dose ibuprofen plus oxycodone for acute postoperative pain in adults. Cochrane Library 2013
  15. Derry CJ, et al. Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain. Cochrane Library 2013