Opioid use disorders are a national and local problem

Editor’s note: In this weekly column addressing medical and health care issues, doctors from Mercer University’s medical school provide useful and timely information on a variety of topics. Readers with questions for the doctors can email them at groover_ce@mercer.edu.

From national medical journals to local newspapers, there has been a steady stream of reporting and discussion on the epidemic of opioid addiction that has in recent years affected our society. Opioid-associated hospitalizations and deaths have become recognized problems at both the national and local level, not only in large cities and suburbs, but also in rural areas such as Appalachia and the desert Southwest. In fact, in rural areas the growth of opioid addiction has been most significant. A commonly quoted statistic is that more people died of opioid-related overdoses in 2014 than died in traffic accidents that year.

Physicians and other prescribers bear some responsibility for the opioid epidemic. During the 1990s, there was increasing interest in hospice. The notion that people with terminal illnesses should be allowed to die with dignity, without undue suffering and without expensive and pointless hospitalizations near the end of life seemed sensible and humane. In parallel with hospice, the idea developed that any type of pain and suffering should be alleviated as much as possible. This included so-called “acute pain,” the kind one experiences following an accident, minor injury or surgical procedure — pain that rapidly, within a few days, resolves.

In general, the most effective treatment for pain, whether acute or chronic, whether as a result of a reversible injury or surgical procedure or from cancer or other progressive, eventually life-ending illness, is an opioid. However, such medications carry with them the unfortunate feature of addiction. For some people, after they get over the pain for which they received opioids, the addictive nature of the medications makes it impossible for them to stop taking them. People, usually after having taken the medications for a prolonged period of time, may become physically addicted, meaning that when they try to stop the medications, they experience physical symptoms such as sweating, jitteriness or restlessness, nausea and vomiting, or severe muscle and joint aches and pains. Others, while not suffering physical symptoms, may become psychologically addicted — just as unable to stop the medications.

In recent years, many people have developed dependence on opioids after having obtained them from ethical practitioners, for legitimate reasons. When those who have developed dependence behaviors are cut off from prescribed opioids, or if those prescribed opioids have become unaffordable, those people sometimes turn to illegal opioids, including heroin. Or, they may obtain legal prescription opioids through illegal means, known as “diversion.”

Because of these problems, the pendulum is swinging in the direction of greater prescriber concern regarding the addictive potential of opioid pain relievers, and many prescribers are hesitant to give their patients prescriptions for opioids, especially in quantity. These prescribers don’t seek to underestimate the discomfort the patient experiences, nor do they wish to under-treat pain, but they are concerned about adding another problem — perhaps ultimately a more severe problem — to their patient’s medical problem list.

For pain that should resolve within a few days, and if opioids are indicated, a prescription for three days’ worth of pain medication should be sufficient. More than seven days of use greatly increases the risk that the recipient will develop opioid dependence.

For chronic pain not related to active cancer treatment, palliative care and end-of-life care, the Centers for Disease Control and Prevention developed a recent guideline for opioid prescribing, which can be viewed at www.cdc.gov/drugoverdose/prescribing/guideline.html. For people or practitioners interested in training in screening and treatment for drug and alcohol use disorders, Mercer University Family Medicine has developed the following program: www.sbirtonline.org.

This story was originally published October 28, 2016 at 3:33 PM with the headline "Opioid use disorders are a national and local problem."