The Opioid Crisis: Considerations for Optimizing Pain Management
Understanding the Epidemic
On October 26, 2017, the Department of Health and Human Services (HHS) declared a public health emergency to address the national opioid crisis, an epidemic claiming 91 lives a day at that time. The opioid crisis began in the 1990’s when pharmaceutical companies pushed these medications, assuring medical professionals that opioids had little to no risk of addiction. The 750,000 people who died from a drug overdose since 1999, 32% of which involved prescription opioids in 2018, tell a different story (Centers for Disease Control and Prevention [CDC], 2020).
In 2017 the U.S. government allotted $900M of the 2017 fiscal budget to opioid specific funding, executing a five-point plan to improve access to support services, increase distribution of overdose-reversing drugs, strengthen data collection methods, support research on addiction/pain, and advance pain management practices (HHS, 2017). This, coupled with efforts by the CDC, HHS, and a number of expert groups, helped contribute to a 4% decrease in drug overdose deaths from 2017 to 2018 (CDC, 2020). However, the number of 2018 drug overdose deaths was still four times higher than in 1999, with an average of 41 people dying daily from overdoses involving prescription opioids (CDC, 2020).
Principles of Pain Management
Pain is often first addressed by a primary care provider during the acute phase, and the goal begins with identification and resolution of the cause of pain (Mills et al., 2016). After a somewhat arbitrary 12 week time period, pain is deemed “chronic” and goals shift to maximizing function and quality of life, rather than total elimination (Mills et al., 2016). Pain is an individual experience, however, and successes in pain management can be largely subjective to each patient.
The HHS established a Pain Management Best Practices Inter-Agency Task Force (Task Force), and in 2019, this reported an extensive literature and research review outlining best practices when treating acute and chronic pain. The Task Force ultimately stressed a patient-centered, multidisciplinary approach for diagnosis and treatment that utilizes multimodal therapies (U.S. Department of Health and Human Services [HHS], 2019). These include non-opioid pharmaceuticals, alternative non pharmaceutical therapies, and safe opioid medication therapy (HHS, 2019).
Providers should not only be aware of the many options to treat pain, but should also understand barriers to care, individual healthcare provider variables, and system obstacles that affect chronic pain management. This may include a prescriber’s biases, access to different treatments, and other conditions that may affect perception of pain.
For example, one study suggested chronic pain treatments should address depression as well as maximize a patient’s self-efficacy in their pain control as this leads to low pain interference of daily life (Adams et al, 2018). Low pain interference was associated with a better quality of life overall with fewer depression/anxiety symptoms, less pain catastrophizing, and greater pain management (Adams et al, 2018).
Addressing Pain: Non-opioid Therapy
Opioids should not be first-line therapy for chronic pain (Dowell et al., 2016). Non-opioid pain therapies can effectively manage chronic pain and are much safer (HHS, 2019). The Task Force recommendations outline all classes of medications that can address pain, encouraging non-opioid pharmaceutical use and alternative pain therapies if appropriate (HHS, 2019).
Addressing Pain: Opioids
Despite negative outcomes, opioids can be effective when addressing pain and can alleviate living with debilitating chronic pain. The 2016 CDC guidelines for the treatment of chronic pain in primary care with opioid therapy addresses initial opioid prescribing as well as ongoing monitoring. These 12 recommendations are aimed at improving communication between health care providers and patients, while reducing risks and incidence rates of negative outcomes associated with opioids (Dowell et al., 2016).
While the guidelines direct prescribing practices for primary care clinicians, pain specialists are an important resource in the appropriate management of chronic pain. The CDC advises pain management consult in cases where substance abuse (or a recent history of), concurrent use of benzodiazepines or other central nervous system depressants, or adequate pain control is not achieved (Dowell et al., 2016).
However, primary care clinicians are often without the ability to consult a specialist or do not have access to a referral program. Either way, knowledge of chronic pain management for primary care providers is imperative in decreasing negative outcomes of opioid therapy.
Adams, M. H., Dobscha, S. K., Smith, N. X., Yarborough, B. J., Deyo, R. A., & Morasco, B. J. (2018). Prevalence and Correlates of Low Pain Interference Among Patients With High Pain Intensity Who Are Prescribed Long-Term Opioid Therapy. The journal of pain : official journal of the American Pain Society, 19(9), 1074–1081. https://doi.org/10.1016/j.jpain.2018.04.005l
Dowell, D., MD, Haegerich, T. M., PhD, & Chou, R., MD. (1970, January 01). CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. November 24, 2020, http://dx.doi.org/10.15585/mmwr.rr6501e1
Mills, S., Torrance, N., & Smith, B. H. (2016). Identification and Management of Chronic Pain in Primary Care: a Review. Current psychiatry reports, 18(2), 22. https://doi.org/10.1007/s11920-015-0659-9
U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human Services website: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html
The Opioid Crisis: Considerations for Optimizing Pain Management
Understanding the Epidemic
On October 26, 2017, the Department of Health and Human Services (HHS) declared a public health emergency to address the national opioid crisis, an epidemic claiming 91 lives a day at that time. The opioid crisis began in the 1990’s when pharmaceutical companies pushed these medications, assuring medical professionals that opioids had little to no risk of addiction. The 750,000 people who died from a drug overdose since 1999, 32% of which involved prescription opioids in 2018, tell a different story (Centers for Disease Control and Prevention [CDC], 2020).
In 2017 the U.S. government allotted $900M of the 2017 fiscal budget to opioid specific funding, executing a five-point plan to improve access to support services, increase distribution of overdose-reversing drugs, strengthen data collection methods, support research on addiction/pain, and advance pain management practices (HHS, 2017). This, coupled with efforts by the CDC, HHS, and a number of expert groups, helped contribute to a 4% decrease in drug overdose deaths from 2017 to 2018 (CDC, 2020). However, the number of 2018 drug overdose deaths was still four times higher than in 1999, with an average of 41 people dying daily from overdoses involving prescription opioids (CDC, 2020).
Principles of Pain Management
Pain is often first addressed by a primary care provider during the acute phase, and the goal begins with identification and resolution of the cause of pain (Mills et al., 2016). After a somewhat arbitrary 12 week time period, pain is deemed “chronic” and goals shift to maximizing function and quality of life, rather than total elimination (Mills et al., 2016). Pain is an individual experience, however, and successes in pain management can be largely subjective to each patient.
The HHS established a Pain Management Best Practices Inter-Agency Task Force (Task Force), and in 2019, this reported an extensive literature and research review outlining best practices when treating acute and chronic pain. The Task Force ultimately stressed a patient-centered, multidisciplinary approach for diagnosis and treatment that utilizes multimodal therapies (U.S. Department of Health and Human Services [HHS], 2019). These include non-opioid pharmaceuticals, alternative non pharmaceutical therapies, and safe opioid medication therapy (HHS, 2019).
Providers should not only be aware of the many options to treat pain, but should also understand barriers to care, individual healthcare provider variables, and system obstacles that affect chronic pain management. This may include a prescriber’s biases, access to different treatments, and other conditions that may affect perception of pain.
For example, one study suggested chronic pain treatments should address depression as well as maximize a patient’s self-efficacy in their pain control as this leads to low pain interference of daily life (Adams et al, 2018). Low pain interference was associated with a better quality of life overall with fewer depression/anxiety symptoms, less pain catastrophizing, and greater pain management (Adams et al, 2018).
Addressing Pain: Non-opioid Therapy
Opioids should not be first-line therapy for chronic pain (Dowell et al., 2016). Non-opioid pain therapies can effectively manage chronic pain and are much safer (HHS, 2019). The Task Force recommendations outline all classes of medications that can address pain, encouraging non-opioid pharmaceutical use and alternative pain therapies if appropriate (HHS, 2019).
Addressing Pain: Opioids
Despite negative outcomes, opioids can be effective when addressing pain and can alleviate living with debilitating chronic pain. The 2016 CDC guidelines for the treatment of chronic pain in primary care with opioid therapy addresses initial opioid prescribing as well as ongoing monitoring. These 12 recommendations are aimed at improving communication between health care providers and patients, while reducing risks and incidence rates of negative outcomes associated with opioids (Dowell et al., 2016).
While the guidelines direct prescribing practices for primary care clinicians, pain specialists are an important resource in the appropriate management of chronic pain. The CDC advises pain management consult in cases where substance abuse (or a recent history of), concurrent use of benzodiazepines or other central nervous system depressants, or adequate pain control is not achieved (Dowell et al., 2016).
However, primary care clinicians are often without the ability to consult a specialist or do not have access to a referral program. Either way, knowledge of chronic pain management for primary care providers is imperative in decreasing negative outcomes of opioid therapy.
If you are interested in learning more…
Understanding the Epidemic | Drug Overdose
Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations
Opioid Pain Medication Prescription for Chronic Pain in Primary Care Centers: The Roles of Pain Acceptance, Pain Intensity, Depressive Symptoms, Pain Catastrophizing, Sex, and Age
Pain Management for Primary Care Providers: A Narrative Review of High-Impact Studies, 2014-2016
Alternative Treatments Fact Sheet
Lessons for Better Pain Management in the Future: Learning from the Past
References
Adams, M. H., Dobscha, S. K., Smith, N. X., Yarborough, B. J., Deyo, R. A., & Morasco, B. J. (2018). Prevalence and Correlates of Low Pain Interference Among Patients With High Pain Intensity Who Are Prescribed Long-Term Opioid Therapy. The journal of pain : official journal of the American Pain Society, 19(9), 1074–1081. https://doi.org/10.1016/j.jpain.2018.04.005l
Centers for Disease Control and Prevention. (2020, March 19). Drug Overdose Deaths. Opioid Overdose. Retrieved December 25, 2020, from https://www.cdc.gov/drugoverdose/data/statedeaths.html
Centers for Disease Control and Prevention. (2020, March 19). Understanding the Epidemic. Opioid Overdose. Retrieved November 25, 2020, from https://www.cdc.gov/drugoverdose/epidemic/index.html
Dowell, D., MD, Haegerich, T. M., PhD, & Chou, R., MD. (1970, January 01). CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. November 24, 2020, http://dx.doi.org/10.15585/mmwr.rr6501e1
Mills, S., Torrance, N., & Smith, B. H. (2016). Identification and Management of Chronic Pain in Primary Care: a Review. Current psychiatry reports, 18(2), 22. https://doi.org/10.1007/s11920-015-0659-9
U.S. Department of Health and Human Services: HHS Press Office. (2017, October 26). HHS Acting Secretary Declares Public Health Emergency to Address National Opioid Crisis. Retrieved November 24, 2020, from https://www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html
U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human Services website: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html
Related Posts
A Review of Healthy People 2030
Takeaways Healthy People 2030 addresses health problems in the US with 355 core objectives that detail the impact of the …
NPACE Notes: November 2022
Table of Content 1. From the Director 2. 2023 Conferences 3. Black Friday Sale 4. Partners of NPACE 5. Monthly …
Migraine Treatment: Abortive Treatment Principles
Devin Pinaroc, FNP-C Takeaways Treatment of migraine episodes is addressed in a stratified or “step” approach, choosing an initial medication …