March 6, 2017

Medical community at odds over how to address Rx opioid overdoses

Daily Briefing

    Restrictions on access to prescription drugs—imposed in an effort to reduce overdose deaths—is causing a "civil war" within the medical community, Bob Tedeschi writes for STAT News.

    A 'civil war'

    CDC data show in 2014 there were a record 47,000 deaths largely related to prescription opioid- and heroin-use in the United States.

    According to Daniel Carr, president of the American Academy of Pain Medicine, providers have clashed over how to address that trend.

    "There's a civil war in the pain community," he said, adding, "One group believes the primary goal of pain treatment is curtailing opioid prescribing. The other group looks at the disability, the human suffering, the expense of

    According to Tedeschi, the "civil war" made it to the mainstream in 2015, when two physicians in a New England Journal of Medicine commentary argued that chronic pain patients needed to focus more on their emotional reactions to pain rather than the reducing the pain's intensity.

    Readers' reactions were swift and divisive, with some readers commending the writers' approach to a pressing public health concern and others criticizing the writers' lack of compassion. According to Tedeschi, the discussion also exposed a lack of scientific evidence about the benefits or harms of long-term prescription opioid use.

    Differing approaches

    "Everyone wants the number of opioid overdoses to fall," Tedeschi writes. However, striking a balance so patients do not lose access to needed medications has proven difficult.

    CDC last March issued guidelines for prescribing opioids, which emphasized alternative treatments and taking steps to prevent misuse in cases when opioids are needed. The guidelines are nonbinding and physicians have adopted different approaches to opioid prescribing.

    How to help patients better manage chronic pain to reduce chronic utilization

    Sean Mackey, a past president of the American Academy of Pain Medicine who now oversees Stanford University's pain management program, said he urges "a thoughtful, balanced approach" to deciding whether to prescribe opioids. "Opioids are a tool—they're more often a fourth- or fifth-line option for me," he said.

    Mackey added that while it can be "healthy" to be hesitant to prescribe opioids, he also has seen cases in which patients have been taking opioid medication for years and are able to manage their pain while also performing daily tasks.

    Others oppose such long-term use.

    Anna Lembke, chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, said long-term opioid-use can cause patients to continue to perceive pain even after the cause of it has been addressed. Some patients do not observe the lack of pain until after they have gone through opioid withdrawal—if they are even able to stop taking the opioids, she added.

    Lembke said when painkillers are necessary, chronic pain patients should take medication "every three days or so" to help avoid developing substance use disorders.

    Meanwhile, chronic pain patients say such views "embolden clinicians, pharmacists, and others to treat them like addicts and criminals," STAT News reports.

    Thomas Yacoe, a patient who has chronic migraines, said, "What people forget is, those who end up on opioid pain management have usually tried everything else unsuccessfully" (Tedeschi, STAT News, 1/17; Rosin, Becker's Hospital Review, 1/17; CDC data, accessed 1/18).

    How to integrate pharmacists into primary care

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