Opioids are a type of drug used to alleviate moderate to moderately severe pain. According to the National Institute on Drug Abuse (NIH), “Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others.” When opioids are ingested, they work by attaching to opioid receptors, which are in one’s brain, spinal cord, gastrointestinal tract, and other organs in one’s body. Opioids adjust the amount of information surrounding pain that is relayed to various areas of one’s body, by reducing one’s perception of pain. Prescription opioid medications are classified as controlled substances.
Important information regarding medication (e.g., controlled substances) that is regulated by the U.S. Food and Drug Administration (FDA) includes the potency, the expiration date, additives and ingredients, and the origin of the medication. All information shared regarding illicit opioids such as heroin, as well as illegally sold opioids is provided solely at the discretion of the manufacturer. This exponentially increases one’s risk of overdose. Because regulated opioids are commonly used in the medical field, their accessibility has grown exponentially over the years, which some believe has contributed to the rise of opioid abuse and addiction.
The opioid epidemic has a significant financial impact on American society. The Centers for Disease Control and Prevention (CDC) explains “the U.S. economic cost of opioid use disorder ($471 billion) and fatal opioid overdose ($550 billion) during 2017 totaled $1,021 billion.” Although opioids have highly addictive qualities, these medications are considered safe when used for a short period of time, under direct supervision of a medical professional. Still, between 8 to 12% of people using an opioid for chronic pain go on to abuse opioids. Approximately 4 to 6% of individuals who misuse prescription opioids transition to heroin. The Centers for Disease Control and Prevention asserts “opioid-involved overdose deaths rose significantly from 46,802 deaths in 2018 to 49,860 in 2019.” According to the World Health Organization (WHO), about 0.5 million deaths are attributed to drug use, worldwide, and more than 70% of these deaths are related to opioids.
The CDC offers different ways to help reduce exposures to opioids and prevent opioid addiction that can be reinforced through:
- Improving programs in health care systems to increase the implementation of recommended prescribing practices.
- Prescription drug monitoring programs (PDMPs).
- Formulary management strategies in insurance programs (e.g., prior authorization, quantity limits, drug utilization review, etc.).
- State prescription drug laws.
- Increasing patient education regarding safe storage practices and disposal of prescription opioids.
- Improving awareness about the risks of prescription opioids, and the cost of overdose on patients and families.
To help primary care clinicians weigh benefits and risks of opioid treatment for chronic pain, in 2016, the CDC released its Guideline for Prescribing Opioids for Chronic Pain. At the same time, new laws, regulations, and policies, some of which were inconsistent with the 2016 guideline, immerged, resulting in its gross misapplication and other harmful effects, illuminating the need for updated guidelines.
On November 4th, 2022, the CDC released the updated version of the Clinical Practice Guideline for Prescribing Opioids for Pain. These guidelines aim to strike a balance between avoiding disruptions to people’s lives and limiting the risks that some attribute to long-term opioid use (e.g., addiction, mental health problems, increased sensitivity to pain, etc.). According to the CDC Factsheet, “to develop the Guideline, CDC followed a transparent and rigorous scientific process using the best available scientific evidence, consulting with experts, and listening to comments from the public and partners.” The new guideline retains the following 2016 principles for prescribing opioids for chronic pain:
- Clinicians should maximize use of nonopioid therapies.
- Consider initiating opioid therapy only if the expected benefits for pain and function are anticipated to outweigh the risks.
- Clinicians should initiate therapy at the lowest effective dosage.
- Carefully evaluate individual benefits and risks when considering increasing dosages.
- Avoid increasing the dosage above levels likely to yield diminishing returns in benefits relative to risks.
Like the 2016 version, the new guidelines are not meant to apply to patients with cancer or sickle cell disease, nor do they apply to end-of-life pain care. A major theme of the 2022 guideline is that people with pain require individualized care, and that prescribers must calibrate doses and timeframes to meet a patient’s distinct needs, while simultaneously minimizing the harms that can come with opioid use.
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