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 2021, 106,699 drug overdose deaths occurred in the United States, which was the highest level of overdose deaths ever reported. 1 Nearly 88% of opioid-involved overdose deaths involved synthetic opioids. In total, more than one million people have died since 1999 from a drug overdose.
Figure 1. Opioid-related overdose deaths by type in the United States 6
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 2018 alone, overdoses involving opioids killed nearly 47,000 people — and 32 percent of those deaths involved prescription opioids. According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health, an estimated 10.1 million people aged 12 and older reported misusing opioids in 2019. 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). 1 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 arew 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. 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.
Book Code: MDAZ1124
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