Responsible Opioid Prescribing for Pain Management
The Takeaway
Prescription opioids can be used appropriately and effectively to manage pain (as well as to treat addiction). However, like many other medications, prescription opioids are powerful and can be dangerous when not used appropriately. The inappropriate overprescribing of opioids beginning in the 1990s has been a major contributor to our modern addiction crisis. Based on current evidence, it’s critical to take steps to reduce the risks and harms of prescription opioids without reducing the availability of opioids when medically necessary.
The Evidence
Medical uses and risks
When prescribed appropriately, opioids can be effective and beneficial for some patients. These medications can be used to manage pain, especially surgical or cancer pain.
There are several risks that come with prescription opioid use for pain management. Chief among them is the development of an opioid use disorder (also known as opioid addiction). It’s important to note that substance use alone does not cause this condition—not everyone who is prescribed opioids will develop an opioid use disorder. Addiction is a complex medical illness that is influenced by genetics, environment, life experiences, as well as exposure. For this reason, it can be difficult to predict which patients may be most at risk. About 8–12% of patients who use opioids to manage chronic pain develop an opioid use disorder.
Overdose—taking too much of a substance, resulting in harmful health effects—is also a risk to be aware of when taking prescription opioids, even when the pills are prescribed. Using alcohol or sedatives while also taking opioids, consuming high dosages of opioids, or having a history of substance use disorder increase a patient’s risk of overdose, which can be fatal.
Like many medications, prescription opioids also have side effects that should be taken into consideration when determining if this is the appropriate medication for an individual. Medical side effects of opioid use include constipation, confusion, depression, as well as increased tolerance (meaning a patient eventually may need higher doses of the medication in order to achieve the same therapeutic effect).
(A footnote here that’s also important to consider: Different formulations of opioids can also be used to treat opioid use disorder. In fact, these medications are considered the gold standard of treatment for this condition, reducing the mortality rate by half or more and helping patients achieve stable, lasting recovery.)
The role of prescription opioid overprescribing in the current addiction crisis
Our country’s most recent addiction crisis has seen several waves. The first began in the 90s, when pharmaceutical companies and opioid distributors, several of whom are currently being sued for their role in the crisis, drove a nationwide increase in opioid prescribing. These companies downplayed the risks of opioids and convinced doctors, policymakers, and the public that these medications were effective and completely safe for a wide spectrum of pain management, despite clear evidence at the time demonstrating the risks of addiction and death. As a result of this deception, more patients were prescribed these powerful medications in large quantities with little to no oversight or consideration for the appropriateness of the medications. This resulted in many more opioids than needed being available to the public, which, without appropriate safeguards, resulted in widespread diversion (meaning the pills ended up on the illegal drug market, to be used for nonmedical purposes) and misuse.
The effects of this were stark. In rural states like Maine and Alabama, OxyContin was prescribed at 2.5–5 times the national average. At the same time, regions like eastern Kentucky saw a 500% increase in patients enrolling in methadone maintenance programs to treat opioid addiction. And across the country, overdose deaths skyrocketed, quadrupling since 1999.
To counteract these trends, crackdowns on opioid prescribing ensued. But unfortunately, those crackdowns did not coincide with increased treatment resources or support for patients who had developed an addiction to prescription opioids. What happened next was a result of supply and demand. As the supply of prescription opioids shrunk, the market for illegal options like heroin swelled. Individuals with opioid addiction could not simply stop being addicted once they were not able to access the amount of prescription opioids they needed, and for many they chose instead to use heroin because it is generally both cheaper and more widely available than prescription opioids. As a result of this trend in use, heroin-related deaths increased. As demand for cheap, available opioids remained high, alternatives like fentanyl became more and more ubiquitous in the drug supply. Fentanyl is a synthetic opioid that is more potent per gram than many other options currently available. Fentanyl is available as a prescription and is also illegally produced. Given its potency, fentanyl is easier and cheaper to traffic than many other illegal opioids, because smaller quantities are needed to produce the same, or an even greater, effect.
We’re currently experiencing a fourth wave of this overdose crisis, which involves polysubstance use, or using multiple substances, rather than just one. Rates of methamphetamine (meth) and cocaine use are rising, and the impact of the trends described above are compounding the risks. Fentanyl is now showing up in areas of the illegal drug supply where it was previously not found, like in stimulant supplies. This can easily result in fatal overdose when those using meth or cocaine consume what they think to be their usual amount of the substance, without taking into account the presence of a powerful opioid.
Access and equity concerns
The addiction crisis our country is currently facing is not its first. Heroin in the 70s, crack cocaine in the 80s—there have been many substance use epidemics that were not caused by pharmaceuticals, but which devastated communities all the same. However, unlike previous addiction crises, this current epidemic has been framed as predominantly an issue among white Americans. This has resulted in a very different approach to solutions, including increased calls for treatment and prevention, rather than criminalization and stigmatization of those with addiction. This shift toward more evidence-based approaches is a step in the right direction. But it’s critical to understand that in order to create lasting, equitable solutions for all Americans devastated by substance use disorders, treatment and prevention solutions, like responsible opioid prescribing, are just one piece of the complex puzzle.
For instance, without a thoughtful and nuanced approach to regulating opioid prescribing, existing inequitable prescribing practices could get worse. For example, bias and institutional racism in healthcare systems has resulted in misperceptions about how Black people experience pain while also stereotyping Black patients as “drug seekers” more frequently than white patients. This has resulted in Black Americans not receiving adequate pain management treatments when in dire need. Truly responsible opioid prescribing will involve righting these wrongs as well.
Further, the stigma of opioid use amid the current overdose epidemic has created problems for patients who have legitimate needs for these medications. Patients living with chronic pain are often classified as “drug seeking” and treated with hostility. Sometimes, they have their treatments abruptly discontinued. Ironically and unfortunately, being kicked off of their controlled prescription medications can lead patients to turn to the dangerous illegal market for relief. This creates many new problems without solving the original issue of reckless overprescribing. Just as addiction patients deserve stigma-free, compassionate, and individualized care, so do pain patients. Opioid prescribing regulations must take these cases into account.
Promising solutions
There is a growing movement advocating for the fact that all care, especially treatment for addiction as well as pain, must be customizable and patient centered. This is beginning to take hold in the American health system and should be supported. Creating policies and protocols that embrace this approach is the key to ensuring that powerful opioid medications are prescribed appropriately and responsibly.
When doctors prescribe opioids, they should be fully aware of potential benefits and risks of these medications, communicating those clearly to their patients. Doctors who are prescribing opioids should have a strong baseline knowledge of how to identify and treat substance use disorders and should know what to do if any patient, whether they are prescribed medication or not, exhibits signs of one. Federal legislation like the Medication Access and Training Expansion Act would make this happen.
To mitigate the risk of fatal overdose, individuals should be able to access the resources they need. Naloxone is a safe, FDA-approved medication that can reverse an opioid overdose in minutes. It should be broadly available, especially to loved ones of people who use opioids. Many pharmacies now offer it over the counter without a prescription, and local harm reduction groups distribute free doses in the communities they serve. Naloxone should also be co-prescribed along with certain opioid medications. Some states, like New York, have recently passed legislation that will make this standard practice.
Household-level risk is also a concern when there are opioid prescriptions in the home. Medications should always be properly secured and stored so that they are not diverted or misused. Patients receiving opioid prescriptions should know that these pills are not like antibiotics—patients don’t necessarily need to finish every prescription. If a prescription is no longer needed, it should be safely discarded.
In general, innovation is needed. Doctors should be empowered to use effective alternatives to opioids in order to treat their patients’ pain. These include nerve blocks, physical therapy, and acupuncture. What’s more, to reduce our health care system’s reliance on opioids for treating pain, finding more safe, effective alternative therapies must become a priority. Pain, as well as its treatment and management, has long gone unresearched and underfunded. When health care professionals better understand pain and how to treat it, prescribing practices and treatment options can improve.
Also, integrated care models that treat the whole patient must become standardized. For example, the Collaborative Care Model is an evidence-based approach that’s proven to improve patient outcomes as well as health equity. By using this model, primary care doctors can address a patient’s needs early on in a holistic and comprehensive way, resulting in more carefully considered prescribing practices as well as improved health for the patient.
One size doesn’t fit all for pain management, and it’s important to take into account the risks and benefits for each patient. When health care systems embrace that fact, opioid prescribing can become safer and more effective.
