Opioids, narcotic painkillers, killed 33,000 Americans in 2015,1,2,3 and nearly 42,250 in 2016 — over 1,000 more deaths than were caused by breast cancer that same year4 — and the addiction trend shows absolutely no signs of leveling off or declining. On the contrary, statistics suggest the death toll is still trending upward, with more and more people abusing these powerful narcotics. According to data5 from the U.S. Centers for Disease Control and Prevention (CDC), overdose cases admitted into emergency rooms increased by more than 30% across the U.S. between July 2016 and September 2017. Overdose cases rose by: 30% among men 31% among 24- to 35-year-olds 36% among 35- to 54-year-olds 32% among those 55 and older Considering opioid overdose is now the No. 1 cause of death of Americans under the age of 50, it’s quite clear we need safer alternatives to pain management and more effective ways to wean off these extremely addictive drugs.
Risk of Addiction Is Very High
Studies show addiction affects about 26% of those using opioids for chronic noncancer pain, and 1 in 550 patients on opioid therapy dies from opioid-related causes within 2.5 years of their first prescription.6 Despite the drugs’ high risk of addiction, a 2016 NPR health poll7 indicated less than one-third of people said they questioned or refused their doctor’s prescription for opioids.
The most common drugs involved in prescription opioid overdose deaths include8 methadone, oxycodone (such as OxyContin®) and hydrocodone (such as Vicodin®). However, as noted by Dr. Deeni Bassam, board-certified anesthesiologist, pain specialist and medical director of the Virginia-based The Spine Care Center, “There’s very little difference between oxycodone, morphine and heroin. It’s just that one comes in a prescription bottle and another one comes in a plastic bag.”9 Indeed, many addicts find the transition from prescription opioids to street drugs like heroin to be a relatively easy one. When a prescription runs out, the cost to renew it becomes unmanageable or a physician refuses to renew a prescription, heroin, which is often cheaper and easier to obtain than opioids, is frequently a go-to solution.
Postsurgical Intervention Lowers Patients’ Risk of Addiction
Unfortunately, many patients are still under- or misinformed about the addictive nature of these pills, and are often not told how to get off them. Addiction can occur within weeks of use, and if a patient is prescribed a narcotic for long-term or chronic pain, addiction is extremely likely. In one 2016 Canadian study, 15% of complex surgical patients developed severe postoperative pain leading to extended use of opioids.10 To minimize the risk of addiction, the Transitional Pain Service at Toronto General Hospital includes follow-up meetings twice a month for the first two months following surgery, and then monthly meetings for another four months. As explained by Science Daily, the goal of these meetings is to “prevent acute pain from becoming chronic post-surgical pain and taper opioid use or wean to zero if possible.”11 To help patients with their pain, the program uses a variety of methods, including nonopioid medications, exercise, acupuncture and mindfulness training, the latter of which has been shown to help patients with pain-related stress and disability, thereby allowing them to successfully wean off higher doses of opioids.12 In the U.S., Stanford University offers a similar program, called the Comprehensive Interdisciplinary Pain Program. These kinds of programs are really crucial, as expecting patients to quit cold turkey is a recipe for disaster.
Many state authorities and insurance companies are now cracking down on opioid use, restricting how much a doctor can prescribe. While this is needed, it leaves long-term opioid users in a pinch. Many who are now unable to refill their prescriptions receive no guidance on how to quit or support to help them find other ways to relieve their pain.
Little Is Known About How to Safely Wean Off Opioids
As noted in Scientific American,13 “… [T]here’s very little research on how best to taper opioids for chronic pain patients. For example, although studies show that drugs such as buprenorphine can help addicts recover, little is known about their value in the context of chronic pain.” One scientific review,14 which included 67 studies on tapering opioids for pain patients found only three of the studies to be of high quality; 13 were found to of “fair” quality while the rest were weak. Still, the evidence available suggested that tapering off the dosage does improve both pain and quality of life. However, the strongest evidence was for multidisciplinary care with close patient monitoring and follow-up — methods that are not widely available and rarely covered by insurance. Scientific American reports:15 “One thing seems clear from research and clinical experience: Reckless restriction is not the right response to reckless prescribing. ‘Forced tapers can destabilize patients,’ says Stefan Kertesz, an addiction expert at the University of Alabama at Birmingham School of Medicine. Worried clinicians such as Kertesz report growing anecdotal evidence of patient distress and even suicide. The brightest rays of light in this dark picture come from a burst of new research. In May a team led by Stanford pain psychologist Beth Darnall published the results of a pilot study16 with 68 chronic pain patients. In four months, the 51 participants who completed the study cut their opioid dosages nearly in half without increased pain. There were no fancy clinics, just an attentive community doctor and a self-help guide written by Darnall. A key element was very slow dose reduction during the first month. ‘It allows patients to relax into the process and gain a sense of trust with their doctor and with themselves that they can do this,’ Darnall says.”
Canadian Study Shows Tapering Dosage Post Surgery Helps
A study17 evaluating the success rate of Toronto General Hospital’s Transitional Pain Service found nearly half of those who had not used opioids prior to surgery successfully weaned themselves off the drugs. Among those who had already used opioids prior to surgery, 1 in 4 was successful. As reported by Science Daily:18 “The study followed patients at high risk for developing chronic pain and problematic opioid use for six months after surgery. In patients who did not take opioids for a year before surgery, the study found that 69 percent were able to reduce their opioid consumption, with 45 percent of them being able to stop completely. Those patients who were taking a prescription opioid before surgery reduced their opioid use by 44 percent, with 26 percent of them weaning off completely. ‘The assumption is that all patients after surgery are fine with their opioid use, but we have found that in a high-risk segment of patients, that is not the case,’ says Dr. Hance Clarke, director of the Transitional Pain Service at [Toronto General Hospital]. ‘We need better ways of identifying these patients, and then helping those who are having difficulty in reducing or eliminating their opioid use. Otherwise, we run the risk of de-escalating patients too fast and having them look elsewhere for opioids or other drugs if we don’t guide them’ … One of the strongest predictors in the study of remaining on opioids long-term after hospital discharge is the dose upon discharge: the higher the dose, the more likely the patient will remain on opioids long-term. For patients who were on opioids before surgery, emotional distress factors such as anxiety or depression, and pain catastrophizing — excessive pain-related worry, along with an inability to deflect thoughts from pain — were important factors in how well these patients could wean off opioids.”
Guidance on Opioid Tapering
Guidance on opioid tapering published in the March/April issue of the Canadian Pharmacist Journal includes the following highlights:19 Adult patients with chronic noncancer pain who are on a 90-milligram (mg) morphine equivalent dose daily or greater should consider opioid tapering to the lowest effective dose and discontinue use if possible Other reasons to consider tapering include lack of improvement in pain and/or function, nonadherence to the treatment plan, signs of addiction, serious opioid-related adverse effects or patient request Prescribers are urged to collaborate with pharmacists to support and monitor patients during opioid tapering A multidisciplinary approach is associated with success in weaning patients off opioids Benefits of tapering include relief of withdrawal symptoms (e.g., pain, sweating or anxiety), reduction in opioid adverse effects…