Increasingly over the past decades, opioids have been prescribed for non–cancer chronic pain. Pain experts have become comfortable with prescribing substantial doses of medications for this population. However, the data supporting the efficacy of these interventions in terms of quality of life and long–term mitigation of symptoms is lacking. In certain conditions such as low back pain and headache, the use of long–term opioids is associated with worsening outcomes, greater pain, and disability. Chronic pain has become a focus of entrepreneurial activities for some. For example, the reimbursement for methadone clinics has resulted in an industry springing up.
There is evidence that the diversion of prescription medications, and in particular opioids, is occurring with disastrous results. Sales over the decade from 1999 to 2010 increased four–fold. The Centers for Disease Control and Prevention estimates that in 2008 there were more than 14,000 deaths related to prescription medications, mostly opioids.
The state I live in, Maine, has the highest rate of diversion of prescription medications in the country. However, no area is exempt. The vast majority of the abused medications are prescribed. At the state level, there is increasing pressure for prescribers to monitor and question the need for chronic opioids. There also is increasing interest in required prescriber education. Deaths, overdoses, and obvious diversion of prescription medications are widespread.
Federally, the Food and Drug Administration is addressing the epidemic by requiring manufacturers to establish a risk evaluation and mitigation strategy, referred to as REMS, for long–acting opioids. Manufacturers are required to develop educational materials that focus on the appropriate use of opioids, counseling the patient and the identification of misuse, dependency, and addiction.
In response to the CDC's report on prescription painkiller overdose deaths, the AAN is addressing this problem by collaborating with the American Pain Society on a NeuroPISM module on Chronic Opioid Therapy (COT), specifically for non–cancer pain. The measures address strategies neurologists should employ to mitigate opioid misuse for COT patients.
What does this mean for neurologists? Most prescribe few medications with abuse potential. Some, particularly those with an interest in chronic pain, prescribe opioids frequently. Whether an occasional or frequent prescriber, particularly for chronic medications, we need to adopt a proactive strategy to avoid diversion and abuse as much as possible. For example, every patient should be on a contract that permits random testing and pill counts. The frequency of refills must be carefully tracked. Those caring for the patient should coordinate who will be responsible for the refills. In the past I know that I personally have been manipulated into prescribing opioids. Hopefully, I am smarter now. An individual I cut off years ago died of an overdose about three months later from prescription medications prescribed by others. In addition to falls, medication mix–ups, and other safety concerns, abuse and diversion of narcotics must be a daily consideration.
Going forward, the federal government is likely to place more restrictions on prescribers and mandatory education is likely. Whether these bureaucratic steps have an impact or not, it is our responsibility to be alert to and act when concerned about misuse of opioids.
Bruce Sigsbee, MD, FAAN