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For the better part of the 20th century, most health-care providers believed that the long-term use of opiods to treat chronic pain was contraindicated by the risk of addiction, increased disability, and lack of efficacy over time.1

Beginning in the 1990s, however, changes in available drug formulations and prescribing practices contributed to an increase in the use of opioid medication among patients with chronic pain conditions.2 Perhaps inevitably, a corresponding rise in the prevalence of opioid abuse and addiction has followed.3


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Treating acute and chronic noncancer pain (CNCP) in the primary-care setting can be challenging. Health-care providers should be knowledgeable of the various classes of controlled substances as well as the potential for abuse among these classes. To minimize the potential for abuse and addiction and to ensure patient safety, evidence-based prescribing practices should be used when treating pain with opioid medications.

In response to the current epidemic of opioid abuse, the FDA recently made dramatic changes to its indications for the use of powerful long-acting and extended-release opioid medications. This medication class is no longer indicated for chronic pain of moderate severity. The updated information states that such drugs are indicated for the management of pain “severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.”4

Overview


In 2011, the CDC reported 12 million nonmedical users of opioids, up from 3.8 million in 2000.5 Opioid abuse represents 75% of the overall problem of prescription drug abuse in the United States.6

The rate of unintentional overdose deaths grew by 124% in the United States between 1999 and 2007, primarily due to the increased incidence of overdoses related to prescription opioids.7 Accidental overdose deaths from opioid use have increased at an alarming rate among females, approaching 400% from 1999-2010, compared with a 250% increase among males during the same period.8

Current data demonstrate a fourfold increase in the prescribing of opioids over the past decade, along with an associated sixfold increase in the number of individuals seeking professional treatment for opioid-related addiction.5

In 2010, U.S. pharmacies dispensed the equivalent of 111 tons of opioids, including 69 tons of pure oxycodone (Oxecta, Oxycontin, Roxicodone) and 42 tons of pure hydrocodone, enough to medicate every individual in the United States for an entire month.9

A 2011 report from the Institute of Medicine (IOM) states that pain is a major reason that individuals seek care from clinicians and recommends that the treatment of pain be considered a nationwide priority.10 The IOM supports updating the prevention, care, education and research related to pain through an evidence-based model.

Despite the tremendous number of opioids consumed in the United States, 116 million Americans per year experience undertreated chronic pain, according to the IOM report.10

Given the severity of the current crisis of prescription drug abuse, health-care providers must be cognizant of the appropriate indications for prescribing opioids, familiar with the individual classes of controlled substances and their abuse potential, and knowledgeable about the potential patient-related risks of prescribing opioids.

Comprehension of and familiarity with these factors will support and encourage the utilization of evidence-based prescribing practices when treating pain. In turn, these practices will minimize inappropriate prescribing and the potential of abuse, addiction, and harm among patients. 


Prescribing opioids


Data have not shown that opioids are a safe or effective treatment for CNCP. The decision to prescribe potentially addictive substances for chronic and non-life-threatening conditions should only be made following careful consideration. Prior to the 1990s, opioids were rarely used for pain associated with such conditions as fibromyalgia, headache, and low-back pain.

The primary indications for opioid medications were for cancer-related pain or for such acute conditions as fractures or surgical interventions. The concern was that use of these powerful substances could lead to addiction, thereby possibly converting a non-life-threatening condition (chronic pain) into a life-threatening one (addiction). 


Prescribing trends


A recent study involving 128 health-care providers revealed that 58% were likely to recommend and prescribe opioids for the treatment of chronic pain–related conditions.11 The beliefs and attitudes expressed by health-care providers in the study indicated that educational gaps exist pertaining to the prescription of opioids.

Finally, the study showed that the number of pain-management specialists available to assist primary-care providers is insufficient; therefore, there is an increasing need for education among primary-care providers regarding the abuse potential of opioids and the use of recommended evidence-based practices when prescribing opioids. 


Deyo et al. conducted an analysis of the electronic health records of 26,014 patients with a diagnosis of low back pain.12 The main purpose of this study was to examine prescribing characteristics associated with long-term opioid use and identify ways to improve safety of opioid prescribing in the primary-care setting.

Electronic pharmacy data and medical-record data for each patient were reviewed for six months before and after an evaluation for low back pain. A total of 15,830 patients (61%) studied were prescribed at least one opioid. Of the patients being prescribed opioids, 4,883 (18.8%) had a history of long-term opioid use during the year they were being treated for low-back pain.

In this study, 92% of the opioids prescribed consisted of the following: hydrocodone and acetaminophen, acetaminophen and codeine, oxycodone and acetaminophen, oxycodone, and morphine. Sedative-hypnotics were co-prescribed for 44% of patients, with benzodiazepines being the most common sedative-hypnotic prescribed.

Finally, the number of diverse opioid prescribers increased among patients with increasing duration of opioid use. Table 1 lists other potentially harmful prescribing trends.


Table 1. Potentially harmful prescribing trends
Prescribing opioids for chronic noncancer pain
Prescribing large quantities of opioids for acute conditions
Prescribing large quantities of opioids without appropriate monitoring or follow-up
Lack of thorough pain assessment prior to prescribing opioids
Prescribing opioids to patients who are at high risk for adverse effects
Co-prescribing opioids with benzodiazepines or other sedatives/hypnotics
Not providing detailed patient education prior to prescribing opioids or other controlled substances