The results of the latest CDC study on the initiation of opioid therapy reflect that the duration of the initial opioid prescription can have a profound impact on whether the patient will still be using opioids after one year (Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265–269). Considering the staggering toll the Rx Drug epidemic causes to our communities, this latest information should help stimulate frank conversations between prescribers and their patients at the outset of any opioid therapy.
Here is the latest data on the epidemic.
Per the latest CDC data:
Drug overdose deaths have nearly tripled in the United States since 1999 (with whites and middle aged Americans bearing much of the brunt);
91 Americans die every day from an opioid overdose (that includes prescription opioids and heroin);
At least half of all opioid overdose deaths involve a prescription opioid;
Each day, more than 1,000 people are treated in emergency departments for not using prescription opioids as directed; and,
As many as 1 in 4 people receiving prescription opioids long term in a primary care setting struggles with addiction.
Based on the above, it should come as no surprise that the number of deaths in the United States from drug poisonings surpasses the number from suicide, homicide, firearms and motor vehicle crashes.
The CDC to the rescue!
While there is no “silver bullet” to solving the Rx Drug epidemic, the CDC has been boldly leading the fight to stem the harmful effects of the Rx Drug epidemic. Earlier this year, Dr. Thomas Frieden, the outgoing head of the CDC, reflected on his seven-year tenure at the helm of the CDC and stated the following:
"When I went to medical school, I was told that if you give an opiate to a patient who has pain, they won't get addicted -- completely wrong... Opiates are highly addictive, and the therapeutic ratio is quite narrow, so if you give a little bit too much, you can die, and after just a few pills, you can be addicted for life ... What we know is that for chronic pain, other modalities of treatment are much safer and can be at least as effective, and may even be more effective."
Dr. Frieden’s comments underscore one of the significant challenges faced by the CDC. Namely, the need to retrain many prescribers and patients about the addictive effects of opioids and the need for safer prescribing practices.
With re-education in mind, in 2016 the CDC released a “Guideline for Prescribing Opioids for Chronic Pain” with several key recommendations including but not limited to:
Consider using non-opioid treatment (as opioids are not first-line or routine therapy for chronic pain);
Start low and go slow (when opioids are started, prescribe them at the lowest effective dose);
Review the PDMP;
Avoid concurrent prescribing (avoid prescribing opioids and benzodiazepines concurrently whenever possible); and,
Offer treatment for opioid use disorder.
Here is the importance of the latest study.
By analyzing patient records relating to the first episode of opioid use among commercially insured, opioid-naïve, cancer-free adults, the study authors hoped to improve prescribing practices by shedding light on the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated. Surprisingly, the authors concluded the following:
“the likelihood of chronic opioid use increased with each additional day of medication supplied starting with the third day, with the sharpest increases in chronic opioid use observed after the fifth and thirty-first day on therapy, a second prescription or refill, 700 morphine milligram equivalents cumulative dose, and an initial 10- or 30-day supply. The highest probability of continued opioid use at one and three years was observed among patients who started on a long-acting opioid followed by patients who started on tramadol.”
In plain terms, there is now scientific evidence that by the third day of opioid use, some patients may be on the path to chronic opioid use. These findings suggest that prescribers and patients should have frank conversations prior to the initiation of opioid therapy and prescribers should review the CDC guidelines with their patients at that time. If you are about to start opioid use and have questions or concerns, review the current guidelines on the CDC website and initiate a frank discussion with your prescriber regarding same.
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This article has addressed one of the latest issues surrounding the Rx drug epidemic. Alix C. Michel is a Chattanooga lawyer at Michel & Ward, PC a litigation firm helping in the fight against the Rx Drug epidemic. The information in this article is not intended to be used as the primary basis for making medical and/or legal decisions, nor should it be construed as a recommendation to follow any course of action specific to a set of facts. You should consult with your prescriber on all medication issues.