TMC PULSE

May 2016 Pulse

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t m c » p u l s e | m a y 2 0 1 6 24 By Shanley Chien I n a landmark move, the United States Centers for Disease Control and Prevention (CDC) recently issued a list of 12 new recommendations for prescribing opioid medications. The unprecedented guidelines are a first from a federal agency to establish ground rules for primary care clinicians to reduce the risk of addiction and curb the opioid epidemic sweeping the country. In an effort to balance pain management with patient safety, the CDC's recommendations include opting for nonpharmacologic approaches and non- opioid therapies—such as ibuprofen, antidepres- sants and anti-inflammatory drugs—rather than morphine, methadone, hydrocodone, oyxodone and other opioid medications for patients outside of active cancer treatment, palliative care and end-of-life care. "We hope that these guidelines will provide a standard that providers can look to that will improve the treatment of pain in the United States, and encourage providers to look at other options in addition to opioids—some of which may work better than opioids in a lot circumstances," said Debbie Dowell, M.D., senior medical advisor for the Division of Unintentional Injury Prevention at the CDC and lead author of the new guidelines. "We haven't used the full array of treatments for pain in the last 15 to 20 years [because] we've relied on opioids increasingly and have forgotten some of the other treatments that may work just as well or better—and certainly have less risk of overdose and opioid use disorder." The country has maintained a long history of overprescribing opioid medications. According to the CDC's most recent study, approximately one in five patients with non-cancer pain or pain-related diagnoses are prescribed opioid medication by doctors. Although the number of opioid prescrip- tions are high among pain medicine, surgery and physical therapy and rehabilitation patients, approximately half of those prescriptions are dis- pensed in excess through well-intentioned primary care providers—so much so that, in 2012, health care providers issued 259 million painkiller prescrip- tions, which was enough to supply each American adult with a bottle of pills, based on a report by the American Society of Addiction Medicine's 2016 report on opioid use. By 2013, about 1.9 million people in the country reported abusing or being dependent on prescription opioid pain medication in that year alone, according to the same report. The new guidelines offer a glimmer of hope for reducing opioid abuse, but prescribing restrictions could also have less-than-savory consequences, particularly in the potential uptick of patients with painkiller addiction turning to illicit drugs, and fuel- ing a current trend in illicit drug use, namely heroin. "In terms of illicit drug use, heroin is the dar- ling," said Matt Feehery, chief executive officer of the Memorial Hermann Prevention and Recovery Center, whose organization treats approximately 200 patients daily who suffer from substance use disorders. "If those people don't go out and get help for their dependence or their addiction, then they're turning to the streets or black market to buy heroin to replace the prescription drug they can't obtain legitimately." Prescription opioids and heroin use are unde- niably linked, with 94 percent of people suffering from opioid addiction admitting that heroin was a far more affordable and accessible alternative to prescription painkillers, according to a 2014 survey published in the Journal of the American Medical Association. Running about $1 per milligram, a single 60-milligram pill of prescription painkiller would cost $60 for the uninsured, so it comes as no surprise that people graduate from highly addictive prescription opioids to heroin for one-fifth of the price and 15 times the potency. "People have that dependence, that need to feed the addiction," Feehery said. "Their brain needs that drug. They want that feeling. That's how the drive gets people to cross the line and go from a prescription medication, like Vicodin or oxyco- done, […] to take heroin." The discussion of the country's widespread prescription painkiller habit is undoubtedly nuanced, hitting at multiple levels of health care and government policy, but the guidelines, in addition to President Barack Obama's recent announcement in March to fight opioid and heroin abuse, serve as overdue first steps in addressing a long-established epidemic. F I R S T I N A T H R E E - PA R T S E R I E S O N O P I O I D A D D I C T I O N P a a R D oX T H E P A I N K I L L E R THE CDC TAKES A HISTORIC STEP FORWARD TO PROMOTE SAFER AND MORE EFFECTIVE ALTERNATIVES TO TREATING CHRONIC PAIN IN AN EFFORT TO MITIGATE THE HIGH RATES OF OPIOID ADDICTION AND DRUG ABUSE People have that dependence, that need to feed the addiction. Their brain needs that drug. They want that feeling. — MATT FEEHERY Chief Executive Officer of the Memorial Hermann Prevention and Recovery Center

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