______________________________ Strategies for Appropriate Opioid Prescribing: The Florida Requirement
In 2011, the American Society of Addiction Medicine (ASAM) published their latest revision in defining the disease of addiction. In 2018, ASAM’s board recognized the need for an updated definition of addiction that would be more accessible to its stakeholder groups, including patients, the media, and policymakers. Accordingly, the Board appointed a Task Force that revised the definition of addiction for use in ASAM’s policy statements. The revised definition states that [10]: Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. EPIDEMIOLOGY OF CHRONIC PAIN AND OPIOID MISUSE Chronic pain affects about 100 million American adults—more than the total affected by heart disease, cancer, and diabetes combined [2]. It also costs the nation up to $635 billion each year in medical treatment and lost productivity and is the leading reason for receiving disability insurance [3; 11]. The lifetime prevalence of chronic pain ranges from 54% to 80%, and among adults 21 years of age and older, 14% report pain lasting 3 to 12 months and 42% report pain that persists longer than one year [2]. While 5 to 8 million Americans receive long-term opioids for the management of chronic pain, an estimated 41% of patients with chronic pain report their pain is uncontrolled, and 10% of all adults with pain suffer from severe, disabling chronic pain [11]. The increasing prevalence of chronic pain is the result of multiple factors, including the aging population; rising rates of obesity and obesity-related pain conditions, such as joint deterioration; advances in life-saving trauma interventions; poorly managed post-surgical pain; and greater public awareness of pain as a condition warranting medical attention [2]. In addition, many armed forces veterans have been returning from military action in Afghanistan and Iraq with traumatic injuries and chronic pain, and veterans’ care clinicians have been reporting the perception that long-term pain management is lacking support in the veteran healthcare infrastructure [12]. There is a widespread misperception that opioid analgesic prescribing and overdose continues to grow, fueling an opioid epidemic [13; 14; 15; 16; 17]. This is refuted by the following data showing that national opioid analgesic prescribing and overdose peaked in 2011 and are in multiyear decline.
According to a report from the National Forensic Laboratory Information System (NFLIS), prescription reports for hydrocodone increased dramatically from 2001 to 2010, but then steadily decreased through 2019. Oxycodone reports increased steadily from 2001 to 2004, and again from 2006 to 2010, and then steadily declined through 2019 [18]. Methadone prescribing data were not captured in the report. Opioid analgesic-associated overdose fatalities have also decreased since 2011, despite published Centers for Disease Control and Prevention (CDC) data reporting a sharp rise in opioid analgesic fatalities in 2014 [19]. This increase was the result of the CDC adding clandestine fentanyl fatalities to figures for prescription opioids in 2014, a difference of more than 4,000 fatalities [20]. The CDC acknowledged this and presented revised 2014 figures with clandestine fentanyl overdoses removed, which supports the belief that opioid analgesic-associated overdose fatalities peaked in 2011 [21; 22; 23]. Opioid analgesic prescribing in the United States has declined from the 2011 peak but remains substantially higher than 1990. Before 1990, physicians seldom prescribed opioids for chronic noncancer pain. By the mid-2000s, 1 of 25 adults was prescribed an opioid for chronic pain, and annual opioid analgesic sales totaled more than $9 billion [25]. There is nearly universal agreement that opioid analgesics were injudiciously overprescribed during the 2000s. Interpretation of the broader trend of increased prescribing from 1990 might be viewed by public health professionals as entirely problematic and by pain medicine professionals as necessary in part, given the past neglect of patients in pain. This reflects the polarized nature of pain care and opioid analgesic prescribing in particular. Efforts to reduce opioid analgesic overprescribing and associated overdose have been successful but have come at a cost to patients who have faced increasing barriers to access, including stigma and abuse in a healthcare system, tapering of opioids without consideration for pain or functional improvements, and difficulty finding a physician [14; 26]. Many prescribed opioid analgesic fatalities result from the co-ingestion central nervous system (CNS)/respiratory depressants (especially benzodiazepines) or prescribed methadone. According to the National Institute on Drug Abuse (NIDA), deaths involving benzodiazepines rose from 1,135 in 1999 to 11,537 in 2017. In 2021, nearly 14% of persons who died of an opioid overdose also tested positive for benzodiazepines [30; 31]. A Canadian study evaluated 607,156 adults prescribed opioids for noncancer pain, and of those whose deaths were related to opioids, co-prescribed benzodiazepines were detected in 84.5% [32]. This is significant considering that dispensed benzodiazepine prescriptions increased more than 36% between 1996 and 2013 [34]. Additionally, many users obtain benzodiazepines by getting prescriptions from more than one doctor, forging prescriptions, or buying the drugs illicitly. Alprazolam and clonazepam are the two most frequently encountered benzodiazepines on the illicit market [18].
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