An epidemic of prescription drug abuse and overdoses is likely to grow worse until there are fundamental changes in the way physicians treat pain, according to a Viewpoint article published in the Journal of the American Medical Association.
“There is little evidence to suggest that physicians have curtailed their practice of prescribing opioids in response to exponential increases in addiction and overdose deaths,” wrote G. Caleb Alexander, MD, an associate professor of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. “Under current regulatory and market conditions, it is likely that a significant and increasing amount of opioids produced to meet clinical demand will be misused or diverted from the legal to illegal markets, leading to more addiction and death.”
The opinion piece is co-authored by Daniel Webster, ScD, a professor of Health Policy and Management at the Bloomberg School and Stefan P. Kruszewski, MD, of MD & Associates.
While prescription opioid medicines have therapeutic value to millions of Americans who suffer from acute and chronic pain, the authors maintain the drugs have contributed to a wave of fatal drug overdoses. The annual number of drug overdoses in the U.S. now exceeds the number of motor vehicle deaths. And overdose deaths from opioids alone — nearly 15,000 in 2008 — exceed the number of overdoses attributed to cocaine and heroin combined.
A variety of regulatory and enforcement strategies have been adopted to limit the abuse and diversion of opioids, such as prescription drug monitoring programs and the prosecution of physicians who overprescribe. But the authors warn those efforts will fail until there is a broader clinical shift away from the widespread use of opioids.
“Prescribing opioids as a matter of course for treatment impedes the opportunity to explore and implement other methods of therapy that could offer relief for millions of Americans who suffer from acute or chronic pain,” said Alexander, who is co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. “It also increases the odds these drugs will be misused or diverted from the legal to the illegal market, leading to more addiction and death.”
The authors recommend that existing measures to prevent abuse and diversion should be complimented by changes in clinical guidelines for the treatment of pain that are less reliant on opioids.
“Greater clinical judiciousness is especially warranted given the limited evidence to support many clinical applications in which opioids are used,” Alexander wrote. “It’s evident more research needs to be done to identify alternative approaches to pain management and treatment, but prescribing practices must change to reverse what has become a pervasive epidemic leading to widespread morbidity, mortality, and community strife.”
The JAMA article adds to the growing debate in the medical community about the prescribing of opioids. The Food and Drug Administration has been petitioned by a group of physicians, scientists and public health officials to change prescription guidelines for opioids.
The FDA currently approves most opioid analgesics for moderate to severe pain, but the petitioners say that is an overly broad definition that has encouraged physicians to prescribe powerful narcotics for long periods to patients who don’t always need them.
“An increasing body of medical literature suggests that long-term use of opioids may be neither safe nor effective for many patients, especially when prescribed in high doses,” the petition states. It calls on the FDA to change the guidelines so that opioids are only indicated for severe pain.
The American Academy of Pain Medicine (AAPM) and other physicians’ groups oppose the petition.
“We have serious concerns about the petition and believe the rationale for the requested changes is seriously flawed, potentially harmful to patients with debilitating pain conditions for whom opioid therapy is indicated, and without substantive scientific foundation,” the AAPM wrote in a letter to the FDA.
One area of agreement is that there is little scientific evidence to support long-term opioid use.
“Indeed, little research has focused on the question of long-term effectiveness of opioid therapy for chronic non-cancer pain. The majority of recommendations from a practice guideline endorsed by the American Pain Society and the American Academy of Pain Medicine are based on lower-quality evidence. At best, the literature has shown inconsistent effectiveness of opioids for chronic pain,” the AAPM letter states.
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