Bulletin from the Opioid Crisis

In the past month alone (July/August 2017), almost a dozen articles and commentaries on the opioid crisis have appeared in major medical journals, with other articles in smaller publications and ongoing top-volume coverage in the lay media. Despite this flood of data and anecdote, urgent questions remain unanswered, including the most pressing concern for primary care clinicians: How best to manage patients who are already taking opioids and those newly requesting relief of serious pain.

A new survey makes clear that, despite all the new cautions, opioids still are being widely prescribed. U.S. researchers used audio computer-assisted self-interviewing to provide participants with a layer of privacy and confidentiality. From a weighted national sample of 51,200 adults, the investigators concluded that 91.8 million adult Americans — more than one third of the entire adult population — took opioids at some point during 2015. Among patients who took opioids, 12.5% confirmed that they misused the drugs (used them without a prescription or in any way contrary to medical direction). In 16.7% of misusers, an opioid-use disorder (as defined in the DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, 4th edition]) could be diagnosed.

These data speak loudly to the dearth of good nonopioid options for pain control. Patients often say they find acetaminophen ineffective, and the NSAIDS have gastrointestinal, renal, and cardiovascular side effects, which can limit their use, particularly in older patients. As New England Journal of Medicine authors outline, a surge of clinicians attempting to control pain without opioids probably is responsible for the steep recent increase in prescriptions for the anticonvulsants pregabalin (Lyrica) and gabapentin. However, these drugs have been proven to be effective only for fibromyalgia and certain forms of neuropathic pain and might prove to be disappointing alternatives for other pain syndromes.

Looking to the future, the directors of the NIH and its Drug Abuse Institute report that a spectrum of novel pain treatments is in the research pipeline. These range from opioids with sophisticated abuse-deterrent properties to nonaddictive agonists for the brain's morphine receptors. Direct brain stimulation and gene therapies lie farther in the future. Also under development are better tools for treating overdose and opioid-use disorders. The government scientists promise effective partnerships between public agencies and private industry to fuel an “all hands on deck” approach to the crisis.

In the interim, though, what are clinicians to do? In a new meta-analysis, researchers sorted through 67 published studies of various strategies for dose-reducing or stopping opioids in amenable patients. Tools evaluated included other drugs (e.g., benzodiazepines, ketamine, clonidine, buprenorphine) and nonpharmacologic techniques such as acupuncture, meditation, and cognitive behavioral therapy. Successful opioid withdrawal with amelioration of pain and improvement in quality of life were reported commonly, but overall the evidence was of such poor quality that no meaningful comparisons between interventions could be structured.

In a prospective study, researchers examined the outcome of a coordinated intervention for primary care practices struggling with opioid misusers. Intensive opioid-care management by a nurse was combined with electronic tracking and decision tools and personal training sessions for providers. The intervention led to significant improvements in guideline-concordant care as well as in rates of opioid dose reduction and discontinuation. The bottom line here is that if some of the basic grunt work of opioid management is shared by a team of trained and willing clinicians, rather than left to the beleaguered primary provider alone, more rational management can be achieved.

Although the quantity of opioid misuse and pathologic abuse in the U.S. indeed is staggering, most individuals can take these medications with neither misuse nor abuse — at least, if we believe the self-reported data in the survey. This conclusion squares with my own clinical experience with many dozens of patients who take long-term opioids for chronic pain, virtually all of whom were first given the drugs by long-vanished providers and who came to my care with their pain management routines cast in cement. Some of them were clearly misusing or diverting medication and stormed off to other sources of care when I declined to participate. The others tolerated slow dose reductions to what I consider reasonable amounts and have been with me ever since, some for decades. Most receive a daily morphine-equivalent of well under 30 mg and lead (as least as far as I can tell) safe and unremarkable lives. Their urine toxicology tests are in order, they are never demanding or abusive, they adhere to treatment for their other medical conditions, and their pain remains a small, routine part of our visits. I was always a reluctant prescriber (New York Times 1995 Oct 29), even back in the days when lavish opioid prescribing was encouraged, not discouraged. These patients, though, actually have convinced me that, with patience and caution, opioids can be used safely and effectively in some people.