Thinking About The Prescription Opioid Medication Crisis

Just a note today on the opioid overdose situation about which a lot of experts are talking including Dr. Jan Fawcett, MD in the October 2015 issue of Psychiatric Annals:

I’m really not sure it’s a great idea to recommend that psychiatrists try taking over as experts in this area. There are mandated CME courses for prescribing opioids in many states including Iowa, which tie physician renewal of medical licenses to completing these courses and this includes psychiatrists, many of whom never prescribe opioids in their practices.

I was very interested in the write up about this topic in the Summer 2015 issue of Iowa Medicine, the Journal of the Iowa Medical Society, sounding a note of concern about the growing problem of opioid abuse in our state:

As the author of the story, Kate Strickler, JD, LLM points out, at least 130 Iowans died from non-heroin opioid overdoses between 2008 and 2010. It’s becoming a familiar story that many people divert prescription opioids from healthcare professionals. About 54% get the drugs for free from a friend who got a prescription from a provider.

While Iowa remains below the overall national rate for use so far, as it relates to prescription drug poisoning, I wonder how long that status will hold:

According to the guest editor in the Psychiatric Annals issue on prescription opioids, Dr. Norman S. Miller, MD, JD, PLLC, “When the evidence is reviewed, there is minimal support for long-term prescribing of opioid medications. An extensive review of over 2,000 publications did not find evidence to justify opioid medication for chronic pain. In addition, there were few articles that researched addiction despite opioid medications’ highly addicting pharmacologic properties. In fact, opioid addiction explains why doctors prescribe and patients consume opioids continuously with substantial risks of psychiatric and medical adverse consequences—and without benefit.”

There is also an article about Opioid Induced Hyperalgesia which I believe I’ve seen as a psychiatric consultant [1]. The treatment is to discontinue the opioid.

We should think very hard before we put one medical specialty in charge of such a complicated problem.

References:

  1. Oberbarnscheidt T, Miller N. Mechanisms of Pain and Opioid Pharmacology. Abstract: Opioid-induced hyperalgesia (OIH) is a very common consequence of pain management with opiods. Characteristics of OIH are worsening pain over time despite an increased dose of the opioid. It is often recognized neither by the physician nor the patient, and it results in increasing doses of opioid medications and continued unsatisfying pain levels experienced by the patient. The increased use of narcotics has a negative impact on patient outcome, as patients suffer from increased pain levels and often develop depression. Patients with OIH require frequent assessment for aberrant behaviors as an indicator of addictive use. Opioid-seeking behavior may complicate the clinical picture of failed opioid therapy. The treatment of OIH is to discontinue the opioid medication and to treat the patient’s withdrawal symptoms, if necessary, in an inpatient setting with medical monitoring. Psychiatr Ann. 2015; 45: 511-515. doi: 10.3928/00485713-20151001-06 [link]

Other abstracts from Psychiatric Annals October 2015 issue on prescription opioids:

Maldow D, Miller N, Matthews A. Do Current Policies and Practices for Prescribing Opioid Medications Solve Chronic Pain Problems? Abstract: Despite the widespread prescribing of opioid medications for the treatment of chronic pain, there is little or no evidence for its efficacy. In fact, the studies show that long-term prescribing of opioid medications leads to significant morbidity and mortality. The Controlled Substance Laws define prescription opioids as dangerous and addicting medications. Despite the classification and scheduling of opioid medication, their prescribing continues to be common and adverse. Most importantly, there are few studies addressing the addicting properties that drive the high rates of prescribing and adverse consequences. It is a myth that most people treated with opioids never become addicted and that addiction does not develop if you are prescribing for pain. Psychiatr Ann. 2015; 45: 500-505. doi: 10.3928/00485713-20151001-04 [link]

Miller N, Farooq U, Matthews A. Psychiatric Diagnoses and Chronic Opioid Use. Abstract: The psychiatric symptoms, particularly depression and anxiety, associated with chronic use of opioid medications as a result of overprescribing are common and debilitating. Opioid medications are classified as depressants and induce serious depression and anxiety, particularly with chronic and persistent use. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides diagnoses for these opioid-induced conditions. Substance-induced disorders, particularly for depression and anxiety, include intoxication and withdrawal, substance/medication-induced depressive disorder, and substance/medication-induced anxiety disorder. Importantly, DSM-5 criteria indicate that diagnoses for major depressive disorder and anxiety disorder cannot be made if there is a substance, such as opioid medications, responsible for the condition. Often the way to distinguish between a substance-induced disorder and an independent major depressive or anxiety disorder is to discontinue the opioid medications. Given that opioids are not efficacious for long-term prescribing, discontinuation of the medication is the treatment of choice. Psychiatr Ann. 2015; 45: 506-510. doi: 10.3928/00485713-20151001-05 [link]

Miller N, Gold M. Prescription Opioids and Addiction. Abstract: Why are opioid medications prescribed in large quantities and high frequency when there is little or no proven efficacy for their therapeutic value? Why are opioids the most commonly prescribed medication in the United States when their adverse consequences continue to grow? Why does the medical profession continue to prescribe opioid medications that result in increased pain and increased disability? This article summarizes the inherent addictive pharmacologic properties that are the impetus and basis for America’s current opioid epidemic. Psychiatr Ann.  2015; 45: 516-521. doi: 10.3928/00485713-20151001-07 [link]

Angres D, DuPont R, Gold M. Perspectives on the Opioid Crisis. Abstract: Health care providers, addiction specialists, and legislators are in agreement that novel and more effective means of reducing opioid and other addicting substance misuse and abuse are critical at this time in our country. The statistics are dismal and increasingly alarming, with more and more individuals at risk. The widespread availability and use of the antiopiate pharmaceutical, naloxone, to reverse life-threatening overdoses is a beginning and a step in the right direction, but can only be considered an initial intervention. What should follow naloxone? We know the answer if the patient is an anesthesiologist resuscitated in the hospital. For everyone who is not a licensed health provider, it is less clear. Substance abuse treatment in the United States is predominantly outpatient, short term, and with few objective checks on the effectiveness of treatment. Substance abuse treatment of health professions is radically different in that it is not a treatment program but is a program of active care management. This management includes residential treatment and sustained monitoring of abstinence. Few addicted patients receive anything that approximates evidence-based care. Psychiatr Ann.  2015; 45: 522-526. doi: 10.3928/00485713-20151001-08 [link]

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Comments

  1. Jim,

    I think psychiatrists should take the lead – but not in prescribing opioids. I have taught a lecture on this issue for the last 5 years. We can lead in the following areas:

    1. The opioid culture: countering the misconceptions that opioids are the magic bullet for chronic pain and what works as well.

    2. Teaching regulators that the problem is not a cognitive deficiency on the part of physicians, therefore doing a CME course will not correct it. I tell my students that we all had the cognitive capacity prescribe opioids as interns.

    3. Teaching regulators and physicians that this is an interpersonal issue and a problem in understanding addictions and managing the relationship with the patient not just prescribing a medication.

    4. Encouraging research on real clinical situations involving the use of opioids.

    5. Political advocacy to decrease the FDA penchant for approving high dose opioids during an opioid epidemic (contrary to the recommendations of their scientific committee).

    G. Dawson

    Liked by 1 person

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