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The Emerging Best Practice on Opioids

Physician Update - April 2016

By Cliff Megerian, MD, President, University Hospitals Physician Services

Opioids have been leading the news in recent months, as the Centers for Disease Control and Prevention (CDC) and the State of Ohio have both released new guidelines for prescribers.
It’s a welcome development. The clinical use of prescription opioids nearly doubled between 2000 and 2010, with overdose deaths now triple what they were in 1990. Incredibly, prescription drugs now exceed automobile accidents as the leading cause of unintentional death.

Thomas R. Frieden, MD, Director of the CDC, has sounded the alarm. He notes that, “it has become increasingly clear that opioids carry substantial risk but only uncertain benefits — especially compared with other treatments for chronic pain. We lose sight of the fact that the prescription opioids are just as addictive as heroin.”

As physicians, it’s imperative for us to understand the scope of the opioid problem. However, studies suggest there is much work to do in this area. A recent study by the Johns Hopkins Bloomberg School of Research found that both physicians and patients mistakenly view their medicines as safe in one form and dangerous in another. The study also found that one-third of physicians are not aware that the most common route by which drugs are administered is by ingestion – not snorting or injection.

These misconceptions have consequences. In a study reported in the Clinical Journal of Pain, researchers found that nearly half of internists, family physicians and general practitioners incorrectly believe that abuse-deterrent pills (medications made with physical barriers to prevent their being crushed and snorted or injected) are less addictive than their standard counterparts.

In fact, the pills are equally addictive. When physicians aren’t aware of this, they may have a false sense of security when recommending opioids for their patients, prescribing them more readily than they should.

Fortunately, the new CDC guidelines recommend what many addiction experts have called for -- that physicians first prescribe ibuprofen and aspirin to treat pain, and that opioid treatment for short-term pain be generally limited to three days, exceeding seven days in only rare instances. However, this is far from current practice. There remains work to do.

As the new guidelines are implemented, there will be new opportunities for education for primary care providers, who prescribe about half of all opioids but who may need more training in how best to use them. The new guidelines also call for urine-testing of patients before issuing opioid prescriptions and increased use of prescription tracking systems to make sure patients are not duplicating prescriptions by “doctor shopping.”

At the state level, Ohio’s new opioid guidelines, drawn up by the Governor’s Cabinet Opiate Action Team (GCOAT), make several recommendations. They advocate that opioid therapy be prescribed only for acute pain (lasting less than 12 weeks), involving tissue damage, an alteration of patient function, or for pain that fades with healing and is expected to resolve within days to weeks. These new guidelines are an important contribution to the ongoing conversation.

With the flurry of media attention the opioid epidemic has generated, the take-home message for physicians is clear: Prescribing opioids is something that should be done with clear knowledge of the risks of addiction it can present.

As UH physicians, we all have a responsibility to familiarize ourselves with these new guidelines and implement them as best practice – for the sake of all our patients.