PracticeUpdate: Dermatology - Vol 1 - No.1 - 2017

RHEUMATOLOGY FEATURE 27

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

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. 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. Author’s Note: The CDC and Surgeons General recommendations for use of

Dr Bonakdar is Director of Pain Management, Scripps

Center for Integrative Medicine, California

VOL. 1 • NO. 1 • 2017