Coupled with rising rates of overdose death are equally dramatic increases in the number of people misusing or abusing opioids. As many as 1 in 4 patients on long-term opioid therapy in a primary care setting are estimated to be struggling with opioid use disorder (OUD), also called opioid addiction. 7-9 In 2016 approximately 11.5 million Americans reported misusing prescription opioids in the previous year. 10 According to the federal Substance Abuse and Mental Health Services Administration (SAMSHA), approximately 80% of heroin users started on their path to addiction after using oral opioid analgesics (either prescribed to them or illicitly). 11 Although the rates of opioid prescriptions have leveled off or declined slightly in recent years, the average days of supply per opioid prescription has continued to rise 10 It is against this background that providers must make daily decisions about how best to treat their patients in pain. Unfortunately, many providers are unfamiliar with the growing evidence base suggesting that opioids are actually not very effective for relieving chronic non-cancer pain in the long-term and, in fact, may be associated with harms such as increased pain, reduced functioning, and physical opioid dependence. 12,13 Providers may also not be aware of the expanding range of both non-opioid medications and non-pharmacological therapies shown to be effective in reducing many common chronic pain conditions. This CME learning activity discusses the management of chronic and acute pain in a variety of patient populations and is structured to conform
to the latest Food and Drug Administration (FDA) Blueprint for Health Care Providers Involved in the Treatment and Monitoring of Patients with Pain (2018). It reviews evidence for non-opioid therapies, including non-drug and non-opioid drug options, as well as current evidence regarding opioid efficacy, harms, and overdose prevention with naloxone, and how to slowly and safely taper opioid doses. Key opioid-related terms Opioid: any psychoactive chemical resembling morphine, including opiates, and binding to opioid receptors in the brain. This term describes opioid and opiates. Opiate: “natural” opioids derived from the opium poppy (e.g., opium, morphine, heroin). Semi-synthetic opioids: analgesics containing both natural and manufactured compounds (e.g., oxycodone, hydrocodone, hydromorphone, oxymorphone). Synthetic opioids: fully-human-made compounds (e.g., methadone, tramadol, and fentanyl). Types of Pain Differentiating between nociceptive and neuropathic pain is critical because the two respond differently to pain treatments. Neuropathic pain, for example, may respond poorly to both opioid analgesics and non-steroidal anti-inflammatory (NSAID) agents. 14 Other classes of medications, such as anti-epileptics, antidepressants, or local anesthetics, may provide more effective relief for neuropathic pain. 15
The challenge of pain management Physicians caring for patients in pain face an unusually daunting set of challenges. As with many other chronic conditions, clinicians must carefully balance expected benefits of treatment with the potential for harm from such treatments. Treating pain, however, involves an additional level of complexity because one of the most commonly-used classes of pain medications—opioids—are at the center of national efforts to stem the epidemic of opioid-related abuse, addiction, and overdose. 1 The United States has seen three successive waves of opioid overdose deaths related to both legal and illegal opioids (Figure 1). 2 The first began in the 1990s and was associated with steadily rising rates of prescription opioids. In 2010, deaths from heroin increased sharply, and by 2011 opioid overdose deaths reached “epidemic” levels as described by the Centers for Disease Control and Prevention (CDC). 3 The third wave began in 2013 with a sharp rise in overdose deaths attributed to synthetic opioids, particularly those involving illicitly-manufactured fentanyl. In late 2020, the CDC announced that 81,230 drug overdose deaths occurred in the 12 months ending in May, 2020, which was the highest level of overdose deaths ever reported. 4 The surge was primarily driven by a 34% increase in overdose deaths related to synthetic opioids, primarily fentanyl. 4 Overdose rates appear to have accelerated during the COVID-19 pandemic. 5 Between 1999 and 2019, the CDC estimates that nearly 500,000 people in the United States died from such overdoses. 6
Figure 1. Opioid-related overdose deaths by type in the United States 6
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