While the dangers of opioid dependence are well-documented, there has been less attention paid to what, specifically, is behind the rise in opioid use and abuse. Many patients who utilize prescription opioids for either acute or chronic pain management did so at the recommendation of a trusted physician. How does a patient go from wanting to manage their pain to dependence on painkillers when the source of the prescription is someone who should be able to know and understand the dangers of opioids?
It turns out that confusion about opioid painkillers may be the largest pitfall to their use.
The first type of confusion rests squarely on the shoulders of doctors. Researchers at Brandeis University, the University of North Florida, and Johns Hopkins University have found that over-prescription of opioids has resulted in excessive non-medical (recreational) use of opioids in communities across the U.S. In a paper published in the Annual Review of Public Health, researchers suggest that the 900% increase of people in the U.S. seeking treatment for opioid addiction since 1997 is a direct result of an overestimation of the benefits of opioids for pain management relative to the risks.
While some patients may see significant benefit from prescription opioid use for chronic pain, the study authors recommend against opioid prescriptions as a knee-jerk reaction to pain. They believe that reducing the number of prescriptions can help address the non-medical opioid issue in the same manner in which a disease outbreak might be managed: by getting at the source of the outbreak and cutting off the supply.
John Eadie, co-author and director of the PDMP Center of Excellence at Brandeis recommends utilizing prescription drug monitoring program (PDMPs) data to alert prescribers to possible doctor-shopping by patients. He notes:
“By encouraging and, if necessary, requiring prescribers to use PDMPs, and by pro-actively sending them prescription data on their patients, states can help medical providers intervene at an early stage of addiction and get patients who need it into treatment.”
This strategy puts the onus for monitoring and careful prescription back onto doctors who should be acting as patient protectors as well as advocates.
It turns out that this protection is exactly what pain patients are looking for from their doctors.
A study from researchers at the Perelman School of Medicine at the University of Pennsylvania found that patients seen in the emergency room for acute pain wanted more information about their pain management options as well as better education about the risks of opioid dependence.
Consistent themes among the 23 study participants include:
- Fear of opioid addiction or dependence
- Information received not from doctors but from acquaintances or other unreliable sources
- Worries about the risks of following dosing guidelines
- Understanding that doctors need to balance pain management with a need for following safe prescription guidelines
Senior author Zachary F. Meisel, MD, MPH, MS, assistant professor and attending physician in the department of emergency medicine, who oversaw the study led by Robert J. Smith, BS, a medical student at Penn, pointed out that even as patients expressed desire for more information about opioids, what they did know what largely from TV and friends, not doctors, saying:
“It was interesting to find that patients believe that taking an opioid as prescribed prevents the possibility of addiction, but also that patients are learning about opioids from television and from friends and acquaintances — not healthcare providers. There’s clearly a significant need for emergency departments to improve education around the risks of opioid misuse.”
Meisel also pointed out that patients in the ER really wanted simple, clear information about opioids in order to make an informed decision that helped them to feel good about their treatment plan:
“Patients want to be given information in a straight-forward way and then listened to, so that they leave feeling like they know what was causing their pain, what their pain management options were, and that their treatment preferences were heard.”
This confusion among doctors and patients about opioid painkillers has resulted in a tightening of prescription guidelines.
Emergency rooms are often an easier place to receive opioids for minor injuries and non-cancer pain due to the fast-paced, high-volume nature of that practice. Because of this, Temple University Hospital (TUH) and Temple University Hospital-Episcopal Campus (TUH-Episcopal) created new opioid prescribing guidelines that immediately reduced prescription rates of opioid painkillers in the emergency room.
Both hospitals looked at data from 13,187 patients aged 18 years or older and the rate of opioid prescriptions for dental, neck/back, and chronic non-cancer pain before and after the new guidelines were put into practice in January 2013. Researchers also interviewed emergency room doctors and found 100% of doctors supported the new guidelines. Ninety-seven percent of doctors also said that the guidelines helped them to more clearly communicate with patients about their options, something that patients had requested.
Daniel del Portal, MD, FAAEM, assistant professor of clinical emergency medicine at the Lewis Katz School of Medicine at Temple University, assistant director of clinical operations at TUH and Jeanes Hospital, and principal investigator of the study, believes that these guidelines allow physicians to work in the best interest of their patients without having to rely on external controls that may not be available (like prescription drug monitoring programs which are not available in all states). He noted that:
“An easily implemented guideline empowers physicians and protects patients from the well documented dangers of opioid misuse.”
This new research seems to point to the importance of clear communication and relationships with healthcare providers when it comes to safe and effective prescription of opioid painkillers and prevention of dependence.
If you are currently utilizing opioids for pain management, talk to your doctor regularly about your options.