Features April 2018 Issue

Response to the Opioid Crisis

To curb opioid misuse, new policies are being put in place to reduce the number of these medications that are prescribed.

America is in the grips of an opioid addiction crisis. There’s no denying that this is a real problem with devastating consequences. In 2016, 63,000 people died from drug overdoses, a 21 percent rise over 2015. About two-thirds of those deaths involved opioids.

Recognizing that abuse of opioid drugs can start with a prescribed medication, the medical community and the government are taking steps to turn the tide.

If you’re taking an opioid medication or think you might need one, you may be wondering how this affects you. Perhaps you worry about your own risk for addiction to these medications. Or you may be concerned that stricter regulations will prevent you from getting pain-relieving medications that you need.

Cleveland Clinic, along with other healthcare institutions, has put new practices and policies into place to deal with the opioid epidemic. We spoke with Lisa Yerian, MD, Medical Director of Continuous Improvement at Cleveland Clinic, and Cleveland Clinic psychiatrist Mohsen Vazirian, MD, about the problem and the response. In this and future issues of Arthritis Advisor we will continue the discussion.

“Opioid drugs are appropriate for some people for some conditions, but for many others there are better options,” says Dr. Yerian.

What Are Opioids?

Let’s start by explaining some terms. Opiates and opioids are related drugs that act on receptors in the brain to alter the way pain is perceived. Derived from a type of poppy plant, opiates include opium and its main ingredients codeine and morphine. Heroin is a semisynthetic derivative of morphine. Synthetic versions of these drugs are called opioids and include oxycodone (Percocet®, OxyContin®), hydrocodone (Vicodin®, Lortab®, Norco®), hydromorphone (Dilaudid®) and fentanyl (Duragesic®). All of these drugs are sometimes referred to as narcotics.

These drugs are powerful pain killers, but they also carry a risk for addiction. Even a person who does not become addicted is likely to develop physical dependence when taking opioids for a long time. Physical dependence means the body adapts to the drug, and stopping it abruptly will cause withdrawal symptoms, such as nausea, vomiting, diarrhea, muscle aches, runny nose, sweating and goosebumps.

A Growing Problem

pill map

© Stuart Ritchie | Dreamstime

The medical community and government are setting new rules to stem the tide of opioid addiction across the country.

“Prior to the mid-1990s not many doctors prescribed narcotics for chronic pain,” says Dr. Vazirian. They were largely restricted to short-term use for severe acute pain, such as postsurgical pain, or for cancer pain.

In recent decades, their use broadened to include more chronic pain conditions. Prescriptions for opioid drugs nearly quadrupled between 1999 and 2014, according to the Centers for Disease Control and Prevention (CDC).

Drug addiction is a complex problem, and many factors play a role. It’s now recognized that the increase in opioid prescribing is partly to blame for the growing overuse and abuse of opioid drugs. Abuse often starts with a legitimate use for a pain condition.

“In 2014, 4 million adolescents and adults reported nonmedical use of prescription pain relievers, meaning they were abusing them,” says Dr. Vazirian. Some people who’ve become addicted to opioids and can no longer obtain them turn to heroin, an initially cheaper alternative. According to a study published in JAMA Psychiatry in 2014, 75 percent of heroin users who began using the drug in the 2000s and sought treatment started with prescription opioids.

“An important message is that there are risks associated with opioids, including the risk for addiction, but also the risk of having opioids in your home,” says Dr. Yerian. If you are taking an opioid, keep it hidden or locked up. “A lot of people find their drugs are stolen, even if they don’t think they know anyone who has a problem with addiction,” she says.

Response

While addiction is a concern with opioids, that does not mean everyone who takes them will get addicted. These powerful medications have a role in pain control. But new rules are being put in place by federal, state and local entities to minimize the chance that their legitimate use will lead to misuse and addiction.

Doctors have become more aware of their prescribing, and more emphasis is placed on nonopioid pain management strategies. If you are prescribed an opioid for any reason, you may find there are limitations on the amount of the drug you can get.

Opioids for Acute Pain

Opioids are commonly used to relieve pain in the first days after a surgical procedure. They may be used for other types of short-term pain conditions as well.

Several state medical boards have put new rules in place for prescribing opioids. For acute pain, the general concept is to consider nonopioid treatment first. When used, opioids should be taken for the shortest time possible at the lowest dosage required to relieve pain.

In Ohio, new rules state that for acute pain adults can receive no more than a seven-day supply of an opioid, with no refills. The duration can be extended only if it can be justified.

Opioids for Chronic Pain

Recommendations differ for use of opioids for chronic pain, meaning pain that lasts longer than three months. According to the CDC, about 25 million adults in the United States suffer with chronic pain. Relieving chronic pain, including from joint conditions or back problems, remains challenging.

For most chronic pain, guidelines from the CDC recommend not using opioids as a first approach to pain relief. (Exceptions are made for people receiving cancer treatment, palliative care or end-of-life care.) Nondrug treatment is preferred. And when medications are used, nonopioids should be tried first.

For painful joint conditions, such as osteoarthritis, opioids actually are less effective than nonsteroidal anti-inflammatory drugs (NSAIDs), which are available both with and without a prescription (such as naproxen [Aleve®] and ibuprofen [Advil®, Motrin®]. Acetaminophen (Tylenol®) is another option.

“For people with chronic pain who cannot get relief, we recommend seeing a pain management specialist who can address both physical and psychological aspects of coping with pain,” says Dr. Vazirian. It’s also important to manage expectations. It may not be possible to achieve zero pain.

There is a role for opioids for treating chronic pain in a small group of people. For example, some people with chronic arthritis pain can’t tolerate the side effects of NSAIDs or can’t take them because of the potential risks, such as stomach ulcers and kidney damage. People who take opioids for chronic pain will be closely monitored by their doctors.

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