__________________________________________________ Responsible Prescribing of Controlled Substances
This disproportionate rate of opioid consumption reflects sociocultural and economic factors and standards of clinical medicine. To assist in monitoring the public health problem associated with prescribed opioids, numerous governmental, non-profit, and private sector agencies and organizations are involved in collecting, reporting, and analyzing data on use and misuse, addiction, fatal overdose, and treatment admissions related to opioid analgesics. The Drug Abuse Warning Network (DAWN) provides annual estimates of drug-related emergency department visits in the U.S, for prescription opioids, heroin, fentanyl, and other opi- oids. In 2022, DAWN found that, among all opioid-related emergency department visits, heroin accounted for 44%, followed by prescription/other opioids (39.4%), and fentanyl (20.8%). Within the prescription/other category, oxycodone was reported in for 32.9% of emergency department visits, followed by hydrocodone (10.7%), tramadol (5.3%), morphine (3.8%), hydromorphone (3.0%), and codeine (1.4%) [7]. As prescription opioid abuse and unintentional overdose has become a growing concern, more emphasis has been placed on prescribing patterns. In 2023, Louisiana had the fourth highest rate of opioid dispensing at 62.7 prescriptions per 100 persons, following Arkansas (71.5 per 100 persons), Alabama (71.4 per 100 persons), and Mississippi (63.1 per 100 person), higher than the national average of 40.1 opioid prescriptions per 100 persons [9]. PAIN MANAGEMENT APPROACHES Healthcare professionals should know the best clinical prac- tices in opioid prescribing, including the associated risks of opioids, approaches to the assessment of pain and function, and pain management modalities. Pharmacologic and non- pharmacologic approaches should be used on the basis of cur- rent knowledge in the evidence base or best clinical practices. Patients with moderate-to-severe chronic pain who have been assessed and treated, over a period of time, with non-opioid therapy or nonpharmacologic pain therapy without adequate pain relief, are considered to be candidates for a trial of opioid therapy. Initial treatment should always be considered indi- vidually determined and as a trial of therapy, not a definitive course of treatment [1; 2]. In response to a growing need for guidance regarding opioid prescribing practices for chronic pain that also limits diversion and misuse, the Centers for Disease Control and Prevention (CDC) released guidelines for opioid prescribing in 2016 [10]. However, these guidelines were met with criticism, and in response, the American Academy of Pain Medicine (AAPM) published a consensus panel report evaluating challenges with implementing the CDC guideline [11]. While the AAPM panel generally agreed with the CDC’s recommendations, it identi- fied six challenges caused by guideline misapplication [11]:
SCOPE OF THE PROBLEM Inappropriate opioid analgesic prescribing for pain is defined as the non-prescribing, inadequate prescribing, excessive prescribing, or continued prescribing despite evidence of ineffectiveness of opioids. Appropriate opioid prescribing is essential to achieve pain control; to minimize patient risk of abuse, addiction, and fatal toxicity; and to minimize societal harms from diversion. The foundation of appropriate opioid prescribing is thorough patient assessment, treatment plan- ning, and follow-up and monitoring. Essential for proper patient assessment and treatment planning is comprehension of the clinical concepts of opioid abuse and addiction, their behavioral manifestations in pain patients, and how these potentially problematic behavioral responses to opioids both resemble and differ from physical dependence and pseudo- dependence [1; 2]. Prescriber knowledge deficit has been iden- tified as a key obstacle to appropriate opioid prescribing and, along with gaps in policy, treatment, attitudes, and research, contributes to widespread inadequate treatment of pain [1; 3]. The extent of opioid analgesic use in the United States was unprecedented in the country’s history and unparalleled anywhere in the world. Before 1990, physicians in the United States were skeptical of prescribing opioids for chronic non- cancer pain. However, by 2011, opioid prescribing reached its peak, with more than 257.9 million opioid prescriptions dispensed. By 2020, the number of opioid prescriptions dispensed was 143.4 million, a decrease of more than 44% since 2011 [4]. Despite the decrease in opioid prescribing, opioid-related overdose deaths are still a primary concern, due largely in part to the increased use and strength of illicit and synthetic opioids [4; 5]. Worldwide consumption of opioid analgesics has increased dramatically in the past few decades, with the United States driving a substantial proportion of this increase. For example, the 1990 global consumption of hydrocodone was 4 tons (3,628 kg), compared with the 2023 consumption of 25.6 tons (23,224 kg); 98.7% of this was consumed in the United States. Similarly, 3 tons (2,722 kg) of oxycodone were consumed globally in 1990, versus 60.2 tons (54,613 kg) in 2023, of which 40.8 tons (37,013 kg or 67.7%) were consumed in the United States [6]. With only 4.5% of the world’s population, the United States annually consumes more than 80% of all
opioid supplies, including [6]: • 99% of all hydrocodone • 68% of all oxycodone • 56% of all methadone • 38% of all hydromorphone • 13% of all fentanyl
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