The Opioid Overdose Crisis

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Page last updated June 10, 2020 by Doug McVay, Editor/Senior Policy Analyst.

26. Opioids and Pain Management

"Opioid analgesics are useful in managing acute and chronic pain. They are sometimes underused in patients with severe acute pain or with pain and a terminal disorder such as cancer, resulting in needless pain and suffering. Reasons for undertreatment include
"• Underestimation of the effective dose
"• Overestimation of the risk of adverse effects
"Generally, opioids should not be withheld when treating acute, severe pain; however, simultaneous treatment of the condition causing the pain usually limits the duration of severe pain and the need for opioids to a few days or less. Also, opioids should generally not be withheld when treating cancer pain; in such cases, adverse effects can be prevented or managed, and addiction is less of a concern.
"In patients with chronic noncancer pain, nonopioid therapy should be tried first (see Chronic Pain : Treatment). Opioids should be used when the benefit of pain reduction outweighs the risk of adverse effects and of drug misuse. If nonopioid therapy has been unsuccessful, opioid therapy should be considered. In such cases, obtaining informed consent may help clarify the goals, expectations, and risks of treatment and facilitate education and counseling about misuse. Patients receiving chronic (> 3 mo) opioid therapy should be regularly assessed for pain control, adverse effects, and signs of misuse. If patients have persistent severe pain despite increasing opioid doses, do not adhere to the terms of treatment, or have deteriorating physical or mental function, opioid therapy should be tapered and stopped.
"Physical dependence (development of withdrawal symptoms when a drug is stopped) should be assumed to exist in all patients treated with opioids for more than a few days. Thus, opioids should be used as briefly as possible, and in dependent patients, the dose should be tapered to control withdrawal symptoms when opioids are no longer necessary. Patients with pain due to an acute, transient disorder (eg, fracture, burn, surgical procedure) should be switched to a nonopioid drug as soon as possible. Dependence is distinct from addiction, which, although it does not have a universally accepted definition, typically involves compulsive use and overwhelming involvement with the drug including craving, loss of control over use, and use despite harm."

"Treatment of Pain." The Merck Manual for Health Professionals. Merck & Co. Inc. Last accessed November 1, 2017.

27. Opioid Use for Pain Management

"'Opioid' is a generic term for natural or synthetic substances that bind to specific opioid receptors in the CNS, producing an agonist action. Opioids are also called narcotics—a term originally used to refer to any psychoactive substance that induces sleep. Opioids have both analgesic and sleep-inducing effects, but the 2 effects are distinct from each other.
"Some opioids used for analgesia have both agonist and antagonist actions. Potential for abuse among those with a known history of abuse or addiction may be lower with agonist-antagonists than with pure agonists, but agonist-antagonist drugs have a ceiling effect for analgesia and induce a withdrawal syndrome in patients already physically dependent on opioids.
"In general, acute pain is best treated with short-acting pure agonist drugs, and chronic pain, when treated with opioids, should be treated with long-acting opioids (see Table: Opioid Analgesicsand Equianalgesic Doses of Opioid Analgesics*). Because of the higher doses in many long-acting formulations, these drugs have a higher risk of serious adverse effects (eg, death due to respiratory depression) in opioid-naive patients."

"Treatment of Pain." The Merck Manual for Health Professionals. Merck & Co. Inc. Last accessed November 1, 2017.

28. Balancing Control And Availability Of Opioid Painkillers In Pain Management

"Because opioid analgesics have both a medical indication and an abuse liability, their prescribing, dispensing, and administration, indeed their very availability in commerce, is governed by a combination of policies, including international treaties and U.S. federal and state laws and regulations. The main purpose of these policies is drug control: to prevent diversion and abuse of prescription medications. However, international and federal policies also express clearly a second purpose of drug control, that being availability: recognizing that many opioids (referred to in law as narcotic drugs or controlled substances) are necessary for pain relief and that governments must ensure their adequate availability for medical and scientific purposes. When both control and availability are appropriately recognized in public policy, and implemented in everyday practice, this is referred to as a balanced approach (American Medical Association?Department of Substance Abuse, 1990; Cooper, Czechowicz, Petersen, & Molinari, 1992; Drug Enforcement Administration et al., 2001; Fishman, 2012; Gilson, 2010a; Gilson, Joranson, Maurer, Ryan, & Garthwaite, 2005; Joranson & Dahl, 1989; Office of National Drug Control Policy, 2011; Woodcock, 2009; World Health Organization, 2011a)."

Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation (CY 2013). (University of Wisconsin Carbone Cancer Center: Madison, WI, July 2014), p. 17.

29. Substance Use Disorders and Effective Pain Treatment

"Persons with substance use disorders are less likely than others to receive effective pain treatment (Rupp and Delaney, 2004). The primary reason is clinicians' concern that they may misuse opioids. Although mild to moderate pain can often be treated effectively with a combination of physical modalities (e.g., ice, rest, and splints) and nonopioid analgesics (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen, or other adjuvant medications), management of severe pain, especially when cancer-related, often requires opioids. Moreover, physicians are increasingly using opioids to treat chronic non-cancer-related pain, and an emerging body of evidence suggests that, for some patients, this approach both reduces pain and may foster modest improvements in function and quality of life (Devulder, Richarz, and Nataraja, 2005; Haythornthwaite et al., 1998; Kalso et al., 2004; Martell et al., 2007; Noble et al., 2008; Passik et al., 2005; Portenoy et al., 2007; Portenoy and Foley, 1986)."

Savage, Seddon R., Kenneth L. Kirsh, and Steven D. Passik. "Challenges in Using Opioids to Treat Pain in Persons With Substance Use Disorders." Addiction Science & Clinical Practice 4.2 (2008): 4–25.

30. Law Enforcement's "Chilling Effect" on Pain Treatment

"The under-treatment of pain is due in part to a kind of undesirable 'chilling effect.' The concept of a chilling effect, generally, is a useful law enforcement tool. When publicity surrounding a righteous prosecution 'chills' related criminal conduct, that chilling effect is intended, appropriate, and a public good. A chilling effect on the appropriate use of pain medicine, however, is not a public good. Recent research by members of the Law Enforcement Roundtable confirms that prosecutions of doctors for diversion of prescription drugs are rare.2 But, on occasion, overly-sensationalized stories of investigation of doctors have hit the nightly news. When that happens, the resulting chilling effect reaches far beyond a 'good' chilling effect on bad actors, and directly affects appropriate medical practice. The consequence is extreme, and not what law enforcement would ever seek – our parents and other loved ones who are in pain simply cannot get the medicines they need."

"Balance, Uniformity and Fairness: Effective Strategies for Law Enforcement for Investigating and Prosecuting the Diversion of Prescription Pain Medications While Protecting Appropriate Medical Practice," Center for Practical Bioethics (Kansas City, MO: February 2009), p. 3.