_______________________________ Prescription Opioids and Pain Management: The Tennessee Guidelines
planning, 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. Prescriber knowledge deficit has been identified 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 [2]. The extent of recent opioid analgesic use (and abuse) in the United States is 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; by 2017, 1 in 25 adults was prescribed an opioid such as oxycodone and hydrocodone for chronic pain, and sales of opioid analgesics totaled more than $9 billion each year [3]. Between 1992 and 2003, the U.S. population increased 14%, while persons using opioid analgesics increased 94% and first-time non-medical opioid analgesic users 12 to 17 years of age increased 542% [4]. It is interesting to note that while opioid prescribing increased precipitously among adults in the United States from 1996 to 2012, the rate remained low and steady for children over the same period [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 2020 consumption of 31.2 tons (28,304 kg); 99.2% of this was consumed in the United States. Similarly, 3 tons (2,722 kg) of oxycodone were consumed globally in 1990, versus 64.9 tons (58,876 kg) in 2020, of which 44.3 tons (40,188 kg or 68.2%) were consumed in the United States [3; 101]. With only 4.5% of the world’s population, the United States annually consumes more than 80% of all opioid
INTRODUCTION Relief from pain leads the list of reasons for seeking medical care, and safe, effective relief of chronic pain is among the most challenging clinical issues in healthcare professionals’ practice. The goals of pain management are to relieve suffering, restore functional capacity, and improve quality of life while minimizing adverse effects and avoiding unintended consequences such as misuse, addiction, and overdose. Prescription opioid analgesics are approved by the U.S. Food and Drug Administration (FDA) for use in treating moderate and severe pain but can also have serious risks and side effects. Opioids are broadly accepted for managing acute pain, cancer pain, and end-of-life care, but are controversial for treatment of chronic pain not caused by a malignancy. In response to the long-standing neglect of severe pain, indications for opioid analgesic prescribing were expanded in the 1990s, followed a decade later by a trend toward inappropriate opioid prescription management and an increase in the prevalence of drug misuse, dependency, and overdose. The conundrum persists: how to provide appropriate and effective treatment of serious chronic pain while avoiding practice patterns that lead to opioid misuse, drug diversion, addiction, and overdose. Common prescription opioids include oxycodone (Oxycontin), hydrocodone (Vicodin), morphine, and methadone. Fentanyl is a synthetic opioid many times more powerful than other opioids, reserved for treatment of severe pain, such as that associated with advanced cancer. Illegally manufactured and distributed fentanyl is a major problem throughout the United States. Patients show substantial variations in opioid analgesic response and tolerability and may exhibit a range of psychological, emotional, and behavioral responses that reflect inadequate pain control, an emerging opioid use problem, or both. The delivery of best practice care to patients with pain requires appreciation of the complexities of prescription opioid use and the dual risks of inadequate pain control and inappropriate opioid use/misuse. The safe and effective use of prescription opioids requires an understanding of the prevalence, causality, and prevention of serious safety concerns attendant to the use of this important class of drugs. SCOPE OF THE PROBLEM Inappropriate prescription opioid analgesia takes several forms: failure to recognize an appropriate indication, inadequate dose titration, excessive opioid dosing, and continued prescription opioid use despite evidence that efficacy is lacking [1]. 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 prescription opioid use encompasses a thorough patient assessment, treatment
supplies, including [4; 101]: • 99% of all hydrocodone • 68% of all oxycodone • 44% of all methadone • 47% of all hydromorphone • 18% of all fentanyl
This disproportionate rate of opioid consumption reflects sociocultural and economic factors and standards of clinical medicine. OPIOID DRUG OVERDOSE In 2005 and 2011, hydrocodone and its combinations accounted for 51,225 and 97,183 emergency department visits, respectively, in the United States. Oxycodone and its combinations resulted in 42,810 visits to the emergency department in 2005; this number increased to 175,229 visits in 2011 [7; 8]. Visits for nonmedical use of all opioids increased from 217,594 to 420,040 during this six-year period.
3
MDTN1726
Powered by FlippingBook