In the light of the buprenorphine treatment that’s often necessary in order to combat prescription opiate addiction, it’s interesting to note two informational pieces published in March 2016 regarding such medications. First, the Journal of the American Medical Association (JAMA) published a study noting that opiate prescriptions issued have increased in recent years for patients who undergo low-risk surgeries. Second, the Centers for Disease Control issued new directives for prescribing opiate pain pills in order to control chronic pain.
So what’s going on the world of prescription opiate addiction and the many people who are so adversely affected by pain pills? The Centers for Disease Control (CDC) tells us that the number of prescriptions written per person between the years 2007 and 2012 increased by 7.3 percent. By 2012, prescribers of all types were writing enough prescriptions to supply every American adult with their very own bottle of pain pills.
That’s a statistic that we’ve all heard before. What was more notable, perhaps, was the fact that family practice, general practice, and internal medicine practitioners were increasing the amount of pain pills they prescribed, while dentists and emergency room doctors were writing for opiates less often.
In the meantime, the JAMA research submitted by clinicians at the University of Pennsylvania School of Medicine warned that patients undergoing routine, low-risk surgeries were going home with prescriptions for medication that could lead to prescription opiate addiction. Doctors were deciding that such minor procedures as carpal tunnel repair, gallbladder laparoscopy, hernia repair, and minimally invasive arthroscopy of the knee merited control of pain using opiates in four out of every five patients. The study results were based on insurance records.
The increase in pain pill prescriptions written defies logic considering that 2.1 million Americans are battling prescription opiate addiction, according to the National Institution on Drug Abuse, and that approximately 22 percent of them will advance from prescription opiate addiction to heroin addiction. The study was limited to patients who had not received opiate pain pills of any kind in the six months prior to their surgeries.
How Do We Avoid Prescription Opiate Addiction?
Here are the Centers for Disease Control’s recommendations for all prescribers to reduce opiate prescriptions issued, summarized in language as concise as possible:
- Prescribers should not write prescriptions in order to treat chronic pain. If they do so, they should not use opiates to treat chronic pain. They should only write for opiates if the need for function and pain relief outweigh the risks of addiction.
- Before prescribing opiates, prescribers should discuss the possibility of prescription opiate addiction with patients and should also engage the patient in a predetermined plan to discontinue the medication.
- Before prescribing opiates, prescribers should discuss the risks and benefits of the medication and of prescription opiate addiction.
- Only immediate-release opiate medications should be prescribed, avoiding the use of extended-release or long-acting opiates.
- The lowest effective dose should be prescribed. Prescribers must reassess risks and benefits if they increase doses to greater than 50 morphine milligram equivalents (MMEs) per day and should avoid increases of or beyond 90 MMEs.
- Three days of opiate medication therapy should be prescribed, and more than seven days will rarely be indicated.
- Within 1 to 4 weeks of starting opiate therapy, prescribers should evaluate the need for continued or increased doses. Continued therapy should be discussed every three months or more frequently. Again, the benefits of opiate therapy must outweigh the risks of prescription opiate addiction.
- Before opiates are presribed, and periodically during this pharmacologic therapy, the risks of prescription opiate addiction including overdose should be discussed. Risk reduction should include a prescription for naloxone if the patient has a history of overdose, a history of prescription opiate addiction, a prescription at or beyond 50 MMEs, or a concurrent prescription for a benzodiazepine medication.
- Prescribers should review the patient’s past history of medications using the state prescription drug monitoring programs (PDMPs) with every prescription written and with every three months of therapy.
- If opiates are prescribed, the prescriber should implement urinary drug monitoring initially and subsequently on an annual basis to check for both prescribed and illicit medications.
- Prescribers should avoid writing for both opiate medications and benzodiazepine medications concurrently.
- Prescribers should refer their patients who exhibit signs of prescription opiate addiction into evidence-based treatment programs, preferably those that utilize methadone or buprenorphine therapy in combination with behavioral treatment.
Considering the stigma that has long been invoked against methadone and buprenorphine treatment programs, there’s a palpable relief shared by professionals who work in local medication-assisted treatment (MAT) programs that the benefits of such therapy have been recognized. The CDC is just one of many federal organizations that has recognized the benefits of MAT, yet both clinicians and patients alike are breathing a collective sigh of relief. As we all wait with baited breath for the House of Representatives to pass CARA, the Comprehensive Addiction and Recovery Act, we can hope that methadone and buprenorphine treatment will become available and affordable for everyone who seeks it.