The Opioid Overdose Crisis

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

31. Using Opioids for Treatment of Acute Pain

"Mild to moderate acute pain is often relieved by physical interventions—such as the application of ice, transcutaneous electrical nerve stimulation (TENS), massage or stretching, and/or bracing—along with a mild analgesic such as an NSAID or acetaminophen. More severe pain often requires opioid therapy, which will be discussed in depth below. When appropriately skilled clinicians are available in a system that is comfortable supporting such treatments, nerve blocks or spinal infusions can sometimes control more severe acute pain. Examples of common acute pain procedures are rib blocks for rib fractures or thoracic incisions; epidural infusions for thoracic, abdominal, or lower body surgery or trauma; and brachial plexus infusions for upper extremity postsurgical or trauma-related pain.
"Clinicians should generally not let concerns about addiction deter them from using opioids that are needed for severe acute pain. Carefully supervised short-term use of opioids in the context of time-limited treatment of such pain has not been documented to affect the long-term course of addictive disorders. Rather, inadequate pain control and treatment that frustrates, stresses, or confuses patients may lead to relapse (Wasan et al., 2006)."

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.
http://www.ncbi.nlm.nih.gov/pm...
http://www.ncbi.nlm.nih.gov/pm...

32. Tighter Prescribing Regulations Drive Illegal Sales

"The US Drug Enforcement Administration introduced a schedule change for hydrocodone combination products in October 2014. During the period of our study, October 2013 to July 2016, the percentage of total drug sales represented by prescription opioids in the US doubled from 6.7% to 13.7%, which corresponds to a yearly increase of 4 percentage points in market share. It is not possible to determine the location of buyers from cryptomarket data. We cannot know, for example, if a drug shipped from a vendor in Europe was purchased by a US customer. Nevertheless, cryptomarket users often prefer buying and selling from vendors in the same country; international shipments carry risks of loss, interception by officials, and increased delivery times. A study of cryptomarkets in Australia found that local vendors were often preferred over international counterparts, despite substantially higher prices.24 Another study36 also noted the downward trends of international sales and therefore an increase in domestic sales, and yet another study47 found that drug trading through cryptomarket is heavily constrained by offline geography. This preference for domestic trading, combined with the relatively large numbers of US drug vendors trading in cryptomarkets, leads us to presume that most sales of prescription drugs by US vendors will be sold to customers based in the US. Conversely, most transactions generated by non-US vendors will not be sold to US customers.

"The results of our interrupted time series suggest the possibility of a causal relation between the schedule change and the percentage of sales represented by prescription opioids on cryptomarkets. Our analysis cannot rule out other possible causal explanatory factors, but our results are consistent with the possibility that the schedule change might have directly contributed to the changes we observed in the supply of illicit opioids. This possibility is reinforced by the fact that the increased availability and sales of prescription opioids on cryptomarkets in the US after the schedule change was not replicated for cryptomarkets elsewhere.

"Our results are consistent with the possibility of demand led increases. The first increase observed for prescription opioids was for actual sales (fig 1); with increases for active listings, and then all listings, following. One explanation is that cryptomarket vendors perceived an increase in demand and responded by placing more listings for prescription opioids and thereby increasing supply. Our results are also consistent with the iron law of prohibition34 insofar as we identified the largest sales increases for more potent prescription opioids—specifically, oxycodone and fentanyl. Cryptomarkets may function as a supply gateway48: customers who initially sought out illicit hydrocodone on cryptomarkets after the schedule change might then have favoured more potent opioids available on the marketplace."

Martin James, Cunliffe Jack, Décary-Hétu David, Aldridge Judith. Effect of restricting the legal supply of prescription opioids on buying through online illicit marketplaces: interrupted time series analysis. British Medical Journal. 2018; 361:k2270.
https://www.bmj.com/content/36...

33. Barriers to Effective Pain Care

"A number of barriers to effective pain care involve the attitudes and training of the providers of care. First, health professionals may hold negative attitudes toward people reporting pain and may regard pain as not worth their serious attention. As discussed in detail in Chapter 2, patients can be at a particular disadvantage if they are members of racial or ethnic minorities, female, children, or infirm elderly. They also may have less access to care if they are perceived as drug seeking or if they have, or are perceived to have, mental health problems. A literature review showed that people with pain, especially women, often have attitudes and goals that are different from, and sometimes opposed to, the attitudes and goals of their practitioners; patients seek to have their pain legitimized, while practitioners focus on diagnosis and therapy (Frantsve and Kerns, 2007). Consumers testified before the committee that patients often believe practitioners trivialize pain, which makes them feel even worse. Researchers working with patient focus groups have noted the 'perceived failures of providers to fully respect, trust, and accept the patient, to offer positive feedback and support, and to believe the participants’ reports of the severity and adverse effects of their pain' (Upshur et al., 2010, p. 1793)."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 153-154.
http://www.nap.edu/openbook.ph...

34. Impact of Drug Control Policy on Medical Treatment of Pain

"Opioid medications also have a potential for abuse (a discussion of this important issue is in the Executive Summary and Section III of the Evaluation Guide 2013). Consequently, opioid analgesics and the healthcare professionals who prescribe, administer, or dispense them are regulated pursuant to federal and state controlled substances laws, as well as under state laws and regulations that govern professional practice.70;71 Such policies are intended to prevent illicit trafficking, drug abuse, and substandard practice related to prescribing and patient care. However, in some states these policies go well beyond the usual framework of controlled substances and professional practice policy, and can negatively affect legitimate healthcare practices and create undue burdens for practitioners and patients,72-76 resulting in interference with appropriate pain management.

"Examples of such policy language include:
  "• Limiting medication amounts that can be prescribed and dispensed for every patient;
  "• Unduly restricting the period for which prescriptions are valid;
  "• Unconditionally denying treatment access to patients with pain who also have a history of substance abuse;
  "• Requiring special government-issued prescription forms only for a certain class of medications;
  "• Requiring opioids to be a treatment of last resort regardless of the clinical situation;
  "• Using outdated definitions that confuse physical dependence with addiction; and
  "• Defining 'unprofessional conduct' to include 'excessive' prescribing, without defining the standard or criteria under which such a determination is made."

Pain & Policy Studies Group, "Achieving Balance in State Pain Policy: A Progress Report Card (CY 2013)" (Madison, WI: University of Wisconsin Carbone Cancer Center, July 2014), p. 11.
http://www.painpolicy.wisc.edu...
http://www.painpolicy.wisc.edu...

35. Undertreated Chronic Pain and Development of Substance Dependence

"In our study, there was greater evidence for an association between substance use and chronic pain among inpatients than among MMTP [Methadone Maintenance Treatment Program] patients. Among inpatients, there were significant bivariate relationships between chronic pain and pain as a reason for first using drugs, multiple drug use, and drug craving. In the multivariate analysis, only drug craving remained significantly associated with chronic pain. Not surprisingly, inpatients with pain were significantly more likely than those without pain to attribute the use of alcohol and other illicit drugs, such as cocaine and marijuana, to a need for pain control. These results suggest that chronic pain contributes to illicit drug use behavior among persons who were recently using alcohol and/or cocaine. Inpatients with chronic pain visited physicians and received legitimate pain medications no more frequently than those without pain, raising the possibility that undertreatment or inability to access appropriate medical care may be a factor in the decision to use illicit drugs for pain."

Rosenblum, Andrew, PhD, Herman Joseph, PhD, Chunki Fong, MS, Steven Kipnis, MD, Charles Cleland, PhD, Russell K. Portenoy, MD, "Prevalence and Characteristics of Chronic Pain Among Chemically Dependent Patients in Methadone Maintenance and Residential Treatment Facilities," Journal of the American Medical Association (Chicago, IL: American Medical Association, May 14, 2003), Vol. 289, No. 18, pp. 2376-2377.
http://jama.jamanetwork.com/ar...

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