Prescription Opioids and Pain Management: The Tennessee Guidelines _ ______________________________
The age-adjusted rate of all-category drug overdose deaths increased from 8.9 deaths per 100,000 standard population in 2003 to 31.3 in 2023 [97]. This sharp increase in the rate of overdose deaths was driven by overdose and inadvertent poisoning deaths involving synthetic opioids (principally fentanyl), indicative of a worsening and expanding illicit drug use epidemic. The age-adjusted rate of drug overdose deaths involving synthetic opioids (e.g., fentanyl) was mostly stable from 2003 (0.5 deaths per 100,000) to 2013 (1.0) and then increased at different rates over time, from 11.4 per 100,000 in 2019 to 22.2 in 2023 [97]. Illicitly manufactured fentanyl and fentanyl analogs are highly potent, increasingly available across the United States, and often found in supplies of other drugs. From 2022 to 2023, drug overdose death rates decreased for non-Hispanic White people, while rates for other race and Hispanic-origin groups generally stayed the same or increased [97]. Overdose deaths involving prescription opioids are now fourfold higher than in 2000. From 1999 to 2020, more than 263,000 people died in the United States from overdoses related to prescription opioids [97]. According to the Centers for Disease Control and Prevention (CDC), 105,007 drug overdose deaths were reported in the United States in 2023, of which 79,358 (75.6%) involved prescription or illicit opioids (primarily synthetic opioids such as fentanyl, fentanyl analogs, and tramadol) [97]. The overdose death rate involving just prescription opioids has fluctuated during the past decade (15,000 to 17,000 per 100,000) before declining to 13,467 in 2023, a 22% decrease in prescription opioid-involved death rates from 2021 to 2023. PUBLIC HEALTH RESPONSE TO THE OPIOID CRISIS To assist in monitoring the public health problem associated with prescribed opioids, numerous governmental, nonprofit, and private sector agencies and organizations are involved in collecting, reporting, and analyzing data on the abuse, addiction, fatal overdose, and treatment admissions related to opioid analgesics. In the past decade, federal and state agencies have convened workgroups consisting of subject matter experts, clinicians, and patient representatives to develop clinical practice guidelines for effective and safe opioid prescription drug use. The 2022 CDC Guideline for Prescribing Opioids for Chronic Pain provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care [10]. The guideline recommendations are grouped in reference to three clinical issues: determining when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; assessing risk and addressing harms of opioid use. The CDC guideline emphasizes the importance of improved communication between providers and patients that enables informed, patient-centered decisions for safe and effective pain care.
Additional opioid prescribing guideline resources for healthcare providers, including clinical tools such as total daily opioid dosage calculators, are maintained by the CDC online at https://www.cdc.gov/overdose-prevention/hcp/clinical-care. TENNESSEE AND THE OPIOID CRISIS In 2011, the state of Tennessee had one of the highest per capita prescription rates for opioids and ranked second in the country for percentage of adult opioid abuse treatment center admissions [92]. According to a 2015 report of opioid abuse in Tennessee, an estimated 212,000 (4.35%) Tennessee adults (18 years of age and older) used pain relievers non-medically in the previous year, the second most prevalent type of drug abuse behind cannabis [93]. From 2014 to 2015, the death rate in Tennessee increased 91% for synthetic opioids (e.g., fentanyl, tramadol), 44% for heroin, and 13% for natural/semisynthetic opioids (e.g., morphine, oxycodone, hydrocodone). The death rate for natural/synthetic opioids was 9.7 per 100,000 population, more than twice the national rate (3.9 per 100,000) [92]. In 2013, the Tennessee legislature, Department of Health, and other agencies came together to address the problem of excessive opioid prescription drug use and the emerging epidemic of drug abuse and overdose. These efforts lead to the creation of a controlled substance database and monitoring program, development of clinical practice guidelines for management of pain and prescription opioid use, and mandated continuing professional education in controlled substance prescribing [94]. There are encouraging signs of progress. From 2016 to 2020, the rate of multiple provider episodes for opioid prescriptions for pain declined from 28.5 per 100,000 residents to 3.5 per 100,000, and opioid prescriptions for pain decreased from 1.98 million dispensed in 2016 to 1.24 million in 2019, representing a decrease of 35.7% [100]. However, in 2022 Tennessee ranked 6th in per capita prescription opioid dispensing rate in the United States. Drug overdose deaths in Tennessee have increased steadily over the past decade (e.g., from 1,776 in 2017 to 3,814 in 2021), and opioids were involved in 80% of these deaths in 2021 [94]. This increase in opioid overdose deaths is largely attributable to the epidemic of illicit fentanyl use and poisonings, which accounted for 2,734 of 3,043 (90%) opioid deaths in 2021, compared with 501 of 1,269 (34%) opioid deaths in 2017. Following a decline in overdose deaths from prescription opioids (e.g., a high of 739 in 2016 to 515 deaths in 2019), the annual number of overdose deaths from prescription opioids increased in 2020 (595) and 2021 (645). The 2023 CDC data summary shows that the age-adjusted prescription opioid overdose death rate in Tennessee was 5.5 per 100,000, compared with 4.1 overall (38 jurisdictions) [91]. In 2020, the number of infants born dependent to drugs, having neonatal abstinence syndrome, totaled 824 in Tennessee [94].
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