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Why Rethink Opioids? Concerns of health care professionals and patients

Concerns About Opioid Therapy Remain Even When the Prescription Is Clinically Appropriate

Health care professionals and patients alike may have concerns with respect to opioid therapy for chronic pain. As a clinician, you may believe an opioid is the right choice clinically in a given situation, but you may feel uncertain about prescribing opioids, for any number of reasons.1-3

Will the patient misuse or abuse the medication?

Prescription opioid abuse is a significant public health problem and patient safety concern. One out of three opioid prescriptions is abused, and those looking to abuse opioids often manipulate them to extract the active ingredient and/or defeat the extended release properties.4 In fact, an estimated 55% of abusers tamper with their opioids.5 All of the most common routes of misuse and abuse are associated with manipulation: oral (chewing, crushing, dissolving), inhalation (crushing), and injection (crushing and dissolving). Click here for more information on methods and routes of prescription opioid abuse.

Will the patient divert the medication? Will the presence of the medication in the patient’s home put family or friends at risk?

Even when prescribing opioids to a responsible patient, there’s a risk that others in the patient’s life may end up taking them. Data indicate that nearly 70% of nonmedical opioid users obtained opioid pain relievers from friends or family.6 Diversion of pills represents significant risk to communities, and attention must be given to reducing the number of opioid pills in the community.

Patients receiving an opioid prescription also may share many of these concerns.1 The potential result: you may not prescribe the opioid, or the prescription may be declined by the patient, and so the pain remains inadequately treated.1,7,8 This suggests the need for risk mitigation strategies that help to reduce the rates of nonmedical use while maintaining access to prescription opioids when indicated and clinically appropriate.9

One approach that may help reduce the risks and address concerns associated with clinically appropriate opioid therapy is the application of universal precautions with every patient being considered for or receiving prescription opioids for chronic pain.2,10-15

Note that the Rethink Opioids initiative focuses on practices that may help to reduce the risks for misuse, abuse, manipulation, and diversion of prescription opioids.

References

  1. Matthias MS, Krebs EE, Collins LA, Bergman AA, Coffing J, Bair MJ. “I'm Not Abusing or Anything”: Patient-physician communication about opioid treatment in chronic pain. Patient Educ Couns. 2013;93(2):197-202. PMID: 23916677
  2. Webster LR, Fine PG. Approaches to improve pain relief while minimizing opioid abuse liability. J Pain. 2010;11(7):602-611. PMID: 20444651
  3. Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: providers' perspectives. Pain Med. 2010;11(11):1688-1697. PMID: 21044259
  4. Barbee G. Breaking down opioid abuse trends in America's workforce. Castlight Health. https://www.castlighthealth.com/2016/04/20/the-opioid-crisis-in-americas.... Published 2018. Accessed November 6, 2017.
  5. Vietri J, Joshi AV, Barsdorf AI, Mardekian J. Prescription opioid abuse and tampering in the United States: results of a self-report survey. Pain Med. 2014;15(12):2064-2074. PMID: 24931057
  6. Substance Abuse and Mental Health Services Administration. NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. Accessed November 6, 2017.
  7. Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Salt Lake City, UT: Utah Dept of Health; 2009. http://www.dopl.utah.gov/licensing/forms/OpioidGuidlines.pdf. Accessed November 6, 2017.
  8. Institute of Medicine of the National Academies. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011. PMID: 22553896
  9. Dowell D, et al. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.
  10. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130. PMID: 19187889
  11. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Version 2.0. Washington, DC: US Dept of Veterans Affairs, US Dept of Defense; 2010. http://www.va.gov/PAINMANAGEMENT/docs/CPG_opioidtherapy_summary.pdf. Accessed November 6, 2017.
  12. Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An Educational Aid to Improve Care and Safety With Opioid Therapy. 2010 Update. Olympia, WA: Washington State Agency Medical Directors Group; 2010. http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf. Accessed November 6, 2017.
  13. Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2—guidance. Pain Physician. 2012;15(3 suppl):S67-S116. PMID: 22786449
  14. Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc. 2009;84(7):593-601. PMID: 19567713
  15. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112. PMID: 15773874