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T
he year 2016, like 2015, continued to be
about approaching the opioid epidemic.
In January, the
Annals of Internal Med-
icine
published “Opioid prescribing after
nonfatal overdose and repeated overdose,”
1
which noted:
•
91% of patients experiencing a nonfatal
opioid overdose continued to receive
prescription opioids, and 7% had a repeat
overdose.
•
Repeat overdosing was significantly
increased with higher-dose opioids or
concomitant use of benzodiazepines.
•
70% of patients who continued to receive
opioids after the overdose obtained them
from a prescriber who had treated them
before the overdose.
Similarly,
JAMA Internal Medicine
published
“Chronic opioid use among opioid-naive
surgical patients,”
2
which noted that several
common procedures, such as mastectomy
and total knee arthroplasty, increase the
odds of chronic opioid use three to five times
in people not previously requiring opioids.
Many potential reasons may exist, including
larger dosing and longer-term dosing than
previously utilised.
Based on these and many other emerging
reports, 2016 saw the release of the CDC’s
clinical guidelines for prescribing opioids
(
www.cdc.gov/drugoverdose/prescribing/
providers.html
).
The guidelines included 12 recommenda-
tions with the top 3 including the following:
1. Use non-opioid therapies
Use non-pharmacologic therapies (such
as exercise and cognitive behavioural
therapy) and non-opioid pharmacologic
therapies (such as anti-inflammatories) for
chronic pain. Don’t use opioids routinely
for chronic pain. When opioids are used,
combine them with non-pharmacologic
or non-opioid pharmacologic therapy,
as appropriate, to provide greater relief.
2. Start lowand go slow
When opioids are used, prescribe the low-
est possible effective dosage and start
with immediate-release opioids instead
of extended-release/long-acting opioids.
Only provide the quantity needed for the
expected duration of pain.
3. Follow-up
Regularly monitor patients to make sure
that opioids are improving pain and func-
tionwithout causingharm. If benefits donot
outweigh harms, optimise other therapies
and work with patients to taper or reduce
dosage and discontinue, if needed.
This was echoed by the Surgeon General
who, in an unprecedented move, sent a let-
ter to every physician in America, telling them
about his campaign to address the opioid cri-
sis
( www.TurnTheTideRx.org ). The campaign
reiterated the CDC guidelines with materials
for physicians to utilise in an attempt to use
non-opioid and non-pharmacological treat-
ment whenever possible in themanagement
of pain.
The push to reduce opioids comes with
attention on how to address those who may
have an opioid-use disorder in clinical care.
Dr Schuckit published an excellent overview
for front-line clinicians in The N
ew England
Journal of Medicine
.
3
2016 also brought attention to a number of
clinical trials examining nonpharmacologi-
cal therapies, which may help fill the void.
JAMA
published results of “Effect of mind-
fulness-based stress reduction vs cognitive
behavioral therapy or usual care on back
pain and functional limitations in adults with
chronic low back pain.”
4
The trial found that both therapies have the
significant ability to reduce pain and func-
tional limitation, with MBSR having sustained
benefits at 52 weeks.
Author’s Note: The CDC and Surgeons
General recommendations for use of
nonpharmacological therapies is a wise step
to help curb opioid overuse and misuse. One
of the key stumbling blocks, especially for
primary care clinicians, is adequate coverage
and access to these therapies. Calling for
reduction of one therapy requires attention
to adequate ability to access the potential
solution. This year, 2017, will see increased
attention on ways clinics; healthcare
systems, and payers are addressing
potential solutions for chronic pain.
References
1. Larochelle MR, Liebschutz JM, Zhang F, et al.
Ann Intern Med
2016;164:1-9.
2. Sun EC, Darnall BD, Baker LC, et al.
JAMA Intern
Med
2016;176:1286-1293.
3. Schuckit MA.
N Engl J Med
2016;375:357-368.
4. Cherkin DC, Sherman KJ, Balderson BH, et al.
JAMA
2016;315:1240-1249.
Dr Bonakdar is Director of
Pain Management, Scripps
Center for Integrative
Medicine, California
The opioid epidemic
By Robert Bonakdar
MD, FAAFP, FACN
Opioid over-prescribing is reaching epidemic proportions but how can
physicians best tackle this?
Dr Robert Bonakdar,
Director, Pain Management at Scripps Center for
Integrative Medicine in California, reviews the current guidelines and
recommendations and offers some solutions
RHEUMATOLOGY FEATURE
27
VOL. 1 • NO. 1 • 2017