U.S. Surgeon General’s “TurnTheTideRx.org”
As part of U.S. Surgeon General Vivek Murthy’s national campaign on the prescription opioid epidemic, he has launched a website called TurnTheTideRx.org, which "provides critical information about opioids, including risks, benefits and clear guidance on how best to prescribe these medications. There are also tools for treatment and in-the-trenches stories from colleagues who are on the front lines of fighting this epidemic."
For more information and to visit the website please Click Here.
Pain Expert: 'I Haven't Prescribed an Opioid in a Decade'
F. Perry Wilson, MD, MSCE; and Daniel Clauw, MD
Daniel Clauw, MD, states the case for avoiding opioids in chronic pain
Daniel Clauw, MD, is professor of medicine, anesthesia, and psychiatry at the University of Michigan and director of the Chronic Pain and Fatigue Research Center. In this era of increasing opioid abuse and overdoses, and harsh criticism for physicians' use of opioids in the setting of chronic pain, he shared his (not at all subtle) opinion in a "Doc to Doc" conversation with me.
Despite treating patients with a range of chronic pain issues, from fibromyalgia to interstitial cystitis to low back pain, Clauw says, "I haven't prescribed an opioid for chronic pain in at least a decade."
Reducing the Risks of Relief — The CDC Opioid-Prescribing Guideline
Deaths from prescription-opioid overdose have increased dramatically in the United States, quadrupling in the past 15 years. Efforts to improve pain management resulted in quadrupled rates of opioid prescribing, which propelled a tightly correlated epidemic of addiction, overdose, and death from prescription opioids that is now further evolving to include increasing use and overdoses of heroin and illicitly produced fentanyl.
The pendulum of opioid use in pain management has swung back and forth several times over the past 100 years. Beginning in the 1990s, efforts to improve treatment of pain failed to adequately take into account opioids’ addictiveness, low therapeutic ratio, and lack of documented effectiveness in the treatment of chronic pain. Increased prescribing was also fueled by aggressive and sometimes misleading marketing of long-acting opioids to physicians.1 It has become increasingly clear that opioids carry substantial risks and uncertain benefits, especially as compared with other treatments for chronic pain.
On March 15, 2016, the Centers for Disease Control and Prevention (CDC) released a “Guideline for Prescribing Opioids for Chronic Pain” to chart a safer, more effective course.2 The guideline is designed to support clinicians caring for patients outside the context of active cancer treatment or palliative or end-of-life care. More research is needed to fill in critical evidence gaps regarding the effectiveness, safety, and economic efficiency of long-term opioid therapy. However, given what we know about the risks associated with long-term opioid therapy and the availability of effective nonpharmacologic and nonopioid pharmacologic treatment options, the guideline uses the best available scientific data to provide information and recommendations to support patients and clinicians in balancing the risks of addiction and overdose with the limited evidence of benefits of opioids for the treatment of chronic pain.
Most placebo-controlled, randomized trials of opioids have lasted 6 weeks or less, and we are aware of no study that has compared opioid therapy with other treatments in terms of long-term (more than 1 year) outcomes related to pain, function, or quality of life.2 The few randomized trials to evaluate opioid efficacy for longer than 6 weeks had consistently poor results. In fact, several studies have showed that use of opioids for chronic pain may actually worsen pain and functioning, possibly by potentiating pain perception. A 3-year prospective observational study of more than 69,000 postmenopausal women with recurrent pain conditions showed that patients who had received opioid therapy were less likely to have improvement in pain (odds ratio, 0.42; 95% confidence interval [CI], 0.36 to 0.49) and had worsened function (odds ratio, 1.25; 95% CI, 1.04 to 1.51).3 An observational case–control study of patients undergoing orthopedic surgery showed that those receiving long-term opioid therapy had significantly higher levels of preoperative hyperalgesia.4 After surgery, patients who had received long-term opioid therapy reported higher pain intensity (a rating of 7.6 vs. 5.5 out of 10) in the recovery room than patients who had not been taking opioids.
Whereas the benefits of opioids for chronic pain remain uncertain, the risks of addiction and overdose are clear. Although partial agonists such as buprenorphine may carry a lower risk of dependence, prescription opioids that are full mu-opioid–receptor agonists — nearly all the products on the market — are no less addictive than heroin. Although abuse-deterrent formulations may reduce the likelihood that patients will inject melted pills, these formulations are no less addictive and do not prevent opioid abuse or fatal overdose through oral intake.
The prevalence of opioid dependence may be as high as 26% among patients in primary care receiving opioids for chronic non–cancer-related pain.2 Risk-stratification tools do not allow clinicians to predict accurately whether a patient will become addicted to opioids, although persons with a history of mental illness or addiction are at higher risk.2 Overdose risk increases in a dose–response manner, at least doubling at 50 to 99 morphine milligram equivalents (MME) per day and increasing by a factor of up to 9 at 100 or more MME per day, as compared with doses of less than 20 MME per day.2 Overall, 1 of every 550 patients started on opioid therapy died of opioid-related causes a median of 2.6 years after the first opioid prescription; the proportion was as high as 1 in 32 among patients receiving doses of 200 MME or higher.5 We know of no other medication routinely used for a nonfatal condition that kills patients so frequently.
The new CDC guideline emphasizes both patient care and safety. We developed the guideline using a rigorous process that included a systematic review of the scientific evidence and input from hundreds of leading experts and practitioners, other federal agencies, more than 150 professional and advocacy organizations, a wide range of key patient and provider groups, a federal advisory committee, peer reviewers, and more than 4000 public comments.
Three key principles underlie the guideline’s 12 recommendations (see The CDC Opioid-Prescribing Guideline). First, nonopioid therapy is preferred for chronic pain outside the context of active cancer, palliative, or end-of-life care. Opioids should be added to other treatments for chronic pain only when their expected benefits for both pain and function are likely to outweigh the substantial risks inherent in this class of medication.
Nonpharmacologic therapies can ameliorate chronic pain while posing substantially less risk to patients. In some instances, other therapies result in better outcomes than opioids. These therapies include exercise therapy, weight loss, psychological therapies such as cognitive behavioral therapy, interventions to improve sleep, and certain procedures. The evidence review conducted in developing the guideline revealed that exercise therapy helped improve, and sustain improvements in, pain and function in patients with osteoarthritis. It did not find evidence that opioids were more effective for pain reduction than nonopioid treatments such as nonsteroidal antiinflammatory drugs for low back pain or antidepressants for neuropathic pain, but it did find that nonopioid treatments could be better tolerated and superior for improving physical function while conferring little or no risk of addiction and substantially lower risks of overdose and death.2
Second, when opioids are used, the lowest possible effective dose should be prescribed to reduce the risks of opioid use disorder and overdose. Clinicians should carefully reassess individual benefits and risks when increasing a dose to 50 MME or more per day. Doses of 90 MME or more should be avoided, or the decision to titrate above this level should be carefully considered and justified. When prescribing opioids, the rule of thumb is to “start low and go slow.”
Third, clinicians should exercise caution when prescribing opioids and should monitor all patients closely. Prescribers should mitigate risk by, for example, avoiding concurrent use of benzodiazepines if possible, reviewing data from a prescription-drug monitoring program when deciding whether to start or continue opioid therapy, offering naloxone at least to patients who are at greater risk for overdose, having a clear “off-ramp” plan to taper and discontinue therapy, reevaluating the dosage and necessity of opioid treatment regularly, and obtaining urine toxicology screening at the initiation of treatment and, for some patients, periodically thereafter. For patients who become addicted to opioids, treatment with methadone, buprenorphine, or naltrexone improves outcomes.
Initiation of treatment with opioids is a momentous decision and should be undertaken only with full understanding by both the physician and the patient of the substantial risks involved. Clinicians need to recognize the risk associated with any treatment with opioids and should prescribe only the shortest course needed. Although the guideline addresses chronic pain, many patients become addicted to opioids after being treated for acute pain. Three days of treatment or less will often be sufficient; more than 7 days will rarely be required. Some trauma and surgery may require longer courses; treatment of postsurgical pain is beyond the scope of this guideline. Furthermore, it is important to discuss storage of opioids in a secure location to prevent diversion, as well as to counsel patients regarding the overdose risk posed to household members and other persons.
Management of chronic pain is an art and a science. The science of opioids for chronic pain is clear: for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits.
The CDC Opioid-Prescribing Guidelines
What opioid painkillers — which kill more Americans than heroin — do to your body and brain
Despite being legal with a doctor's prescription, opioid painkillers can come with serious health risks. The drugs belong to a larger class of drugs known as opioids, which includes legal, lab-produced drugs like oxycodone, fentanyl, and morphine as well as illegal drugs like heroin. Since they slow breathing and act on the same brain systems as heroin, opioid painkillers carry serious risks, from overdose to, in rarer cases, addiction.
We all have a series of naturally produced keys ("ligands") and keyholes ("receptors") that fit together to switch on our brain's natural reward system — it's the reason we feel good when we eat a good meal or have sex, for example.
But opioids mimic the natural keys in our brain — yes, we all have natural opioids! When they click in, we can feel an overwhelming sense of euphoria.
When prescription painkillers act on our brain's pleasure and reward centers, they can make us feel good. More importantly, though, they can work to reinforce behavior, which in some people can trigger a repeated desire to use. Read more here: http://www.businessinsider.com/mental-physical-effects-of-opioids-2016-5
Coalition to Stop Opioid Overdose Resources
Help get the word out by exploring the following promotion tools which you are free to use in your efforts:
Opioid misuse and overdose, which are rising at unprecedented rates, are public health crises in the United States. There is an urgent need for simple and achievable prevention, treatment and recovery policies that can reduce opioid overdose. The Coalition to Stop Opioid Overdose unifies diverse groups around common policy goals and a coordinated strategy that will lead to meaningful and comprehensive opioid overdose prevention policy.
The Coalition to Stop Opioid Overdose is an organization of state and national groups that are committed to advancing meaningful legislative and regulatory policies in response to the opioid epidemic. The Coalition’s efforts will focus around five key strategies to combat the opioid epidemic:
- Improving access to medication-assisted treatment for those with opioid addiction.
- Expanding availability of naloxone in healthcare settings and beyond.
- Enactment of the Comprehensive Addiction and Recovery Act (CARA).
- Enhancing prescription drug monitoring programs that track the dispensing and prescribing of controlled substances.
- Raising the level of opioid prescriber education.
Dr. Slack’s “Six point checklist to more discriminating opioid prescribing”
- How definable is the source of pain?
- SCREEN for risk of addiction
- Consider ALL treatment options
- If opioids are prescribed:
- LOWEST Effective dose
- LOWEST number of pills
- Educate on Georgia 9-1-1 Medical Amnesty Law
- EDUCATE the patient
- Risks / benefits of opioid use
- Sharing opioid medications is illegal
- Proper storage / disposal
- MONITOR the patient for misuse / diversion
- Prescription Drug Monitoring Program
- Controlled substances agreement
- Drug Screening / pill counts