Published in the June 2016 issue of Today’s Hospitalist
THE “BIG BOOK“ of Alcoholics Anonymous was first published in 1939. Back then, alcohol was public enemy no. 1 when it came to addiction, followed arguably by tobacco.
How times have changed! The opioid epidemic is entering its second decade and shows no signs of abating. According to the Substance Abuse and Mental Health Services Administration, opioids (heroin and prescription pain pills) now top the list of reasons for addiction treatment (28.5% of all admissions), followed by alcohol (21.2%) and marijuana (16.6%).
Coincident with this has been all sorts of carnage. The CDC recently reported that opioid overdose deaths have increased 200% since 1990, while the number of ED visits for misadventures with narcotic pain relievers more than doubled between 2005 and 2011.
Coincident with the opioid epidemic has been all sorts of carnage.
I could bury you with other scary and sober statistics, but I’ll cite just one more: Vicodin (hydrocodone/acetaminophen) has been the no. 1 prescribed medication in the U.S. for years running. About 135 million prescriptions were dispensed in 2012.
Tramadol (don’t delude yourself!) and Percocet (oxycodone/acetaminophen) are no. 21 and no. 22 on the list, respectively. I’m board certified in addiction medicine and have a major practice focus on opioid addiction, but hospitalists everywhere know the problem is huge.
How doctors became drug dealers
The current opioid crisis resulted from a perfect storm that began about 20 years ago. Purdue Pharma received FDA approval for OxyContin, the controlled-release formulation of oxycodone, in 1995. The following year, the American Pain Society declared pain the fifth vital sign, and the Joint Commission later piled on with some pain-related standards.
The Federation of State Medical Boards introduced its “Model Guidelines for the Use of Controlled Substances for the Treatment of Pain” in 1998. According to the 2004 update, “undertreatment of pain is recognized as a serious public health problem.” In other words, you were negligent for failing to provide adequate pain control.
The tipping point, however, was a joint consensus statement on chronic pain approved in 1996 by the American Academy of Pain Medicine and the American Pain Society, which effectively green-lighted opioid prescribing. It noted, for example, that “for most opioids, there does not appear to be an arbitrary upper dosage limit, as was previously thought.”
Voila! The genie was out of the proverbial bottle.
Russell Portenoy, MD, is considered the prime architect of the opioids-for-chronic-pain sea change. He got the ball rolling in 1986 with a now-famous case series that optimistically concluded, “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable nonmalignant pain and no history of drug abuse.”
By 2010, however, Dr. Portenoy was having doubts. “I gave innumerable lectures in the late 1980s and ’90s about addiction that weren’t true,” Dr. Portenoy said in a private interview later obtained by the Wall Street Journal. Although he was more circumspect when contacted directly by reporters, he still conceded, “Data about the effectiveness of opioids do not exist.”
Enter the new “CDC Guideline for Prescribing Opioids for Chronic Pain,” published by the CDC in March and republished by JAMA in April.
The authors initially addressed five key questions, including whether long-term opioid therapy improves pain, function and quality of life. Consistent with Dr. Portenoy’s prior comment, the authors—remarkably, depressingly—were unable to find any (zero!) good-quality studies to inform their analysis.
The authors presented 12 recommendations for prescribing opioids for patients with chronic pain that isn’t due to active cancer or palliative and end-of-life care. Most are old hat, including using non-pharmacologic and non-opioid options and starting with the minimum effective opioid dose. Ditto for consulting prescription drug monitoring programs, periodic urine drug testing and avoiding concurrent benzodiazepine therapy.
There is, however, a possible game-changer dealing with opioid dosing. The authors stated that clinicians “should carefully reassess evidence of individual benefits and risks when increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid increasing dosage to 90 MME or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day.” They also suggested “offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/d), or concurrent benzodiazepine use are present.”
Consider the not-uncommon patient on your service who takes prescription opioids for chronic back pain. His current regimen is OxyContin 80 mg every 8 hours plus another 120 mg of the immediate release formulation throughout the day. That’s a whopping 540 MME. Yikes!
Hospitalists are invariably on the receiving end of chronic pain. How do these ostensibly ambulatory guidelines apply to you?
Justice Louis Brandeis is possibly best remembered for this aphorism: “Sunlight is said to be the best of disinfectants; electric light the most efficient policeman.” In modern health care, the electronic health record can effectively serve as both.
I’m not advising you to throw anyone under the bus. But you can draw attention to the CDC guideline in your documentation, maybe in the form of a checklist.
Consider this lead-in: “The patient’s treatment plan was considered in light of the CDC’s new guideline for opioid therapy for chronic pain (JAMA 2016;315:1624).” From there, you could follow with some bullets:
- Prescription drug monitoring program: no worrisome pharmacy activity.
- Urine toxicology: positive for prescribed medications; negative for illicit drugs and nonmedical medications.
- Opioid dosing: currently exceeds 90 morphine milligram equivalents per day.
- Concurrent benzodiazepine therapy: patient takes alprazolam for anxiety.
I’d probably leave it at that. If you feel the need to embellish (or cover your ass), toss this in: “Will send patient home with a naloxone auto-injector (Evzio).”
Remember, this problem—individually and societally—didn’t occur overnight, and you generally can’t undo iffy treatment plans in a single hospitalization. You can, however, create awareness and deliver subtle nudges in the right direction.
David A. Frenz, MD, is vice president and medical director for North Memorial Health Care in Robbinsdale, Minn. You can learn more about him and his work at www.davidfrenz.com or LinkedIn.