Introduction

According to the National Institute on Drug Abuse, in 2017 the United States of America (US) had 72,306 deaths occur due to drug overdoses; 49,068 (67.8%) of those deaths were secondary to opioids.¹ On a daily basis, it is estimated that 115 people in the United States die due to opioid overdose.² Internationally, the WHO reported that opioid use disorder was responsible for 33-50% of all drug-related deaths, thereby causing 118,000 deaths in 2015.³

 

What are opioids?

An opioid, a natural or synthetic substance, stimulates its analgesic and euphoric effects on the central nervous system by acting on the following opioid receptors: mu, kappa, and delta.¹ Activation of the mu receptors results in CNS responses, such as respiratory depression, analgesic effects, and euphoria.³ Opioids can be administered orally, intranasally, intravenously, subcutaneously, and intramuscularly. However, heroin, the most commonly abused opioid, is commonly administered via injection.³

 

Why are opioids prescribed?

Recently, prescribing opioids for surgery, injuries, chronic health conditions, and chronic pain has dramatically increased, despite some serious risks and lack of evidence regarding their efficacy.⁴ Methadone, Oxycodone, and Hydrocodone are amongst the most commonly prescribed opioids for chronic pain management.⁴ In 2015, 91 million civilians in the US were prescribed opioids, with the most common motivation being relief of physical pain (63.4%).⁵ Among the majority of adults with opioid misuse, 59.9% of the drugs were obtained without a prescription, while 40.8% were prescribed by health care professionals.⁵

 

How do we combat the opioid epidemic?

Physicians are constantly facing ethical dilemmas when managing chronic pain. Pain relief is one of the fundamental obligations of medical health professionals.⁶ As prescribing opioids has created a “public health crisis,” many physicians have decided entirely to avoid opioid prescriptions.⁶ However, as 1 in 5 adults live with chronic pain, the failure to adequately treat chronic pain can lead to suboptimal patient outcomes and poor quality of life.⁶ As a result, physicians are under pressure to prescribe opioids to relieve suffering and pain, and maintain the doctor-patient relationship.⁷ Although opioid overdose has become an epidemic, the following are some strategies to combat this epidemic:

1. Chronic pain management costs the Canadian health system an estimated $6 million per year.⁷ Budget allocations of resources should be re-distributed to services and facilities that assist in the management of chronic pain, such as physiological services, physical therapy, and occupational therapy.⁷
2. Physicians should work in collaboration with other health care professionals who specialize in optimizing chronic pain management (pharmacists, anesthesiologists, and palliative care teams).⁷ Also, by equipping health care professionals with appropriate resources and evidence-based medicine, we can enhance chronic pain management and increase patient safety.⁸ In the setting of chronic pain management, non-pharmacological therapy (physical treatments, behavioural therapy, and interventional treatments) and non-opioid therapy (NSAIDS, acetaminophen, ibuprofen) are preferred.⁹
3. In the setting where the benefits of alleviating pain are anticipated to outweigh the risks, opioids may be initiated with caution.⁹ In this setting, patients should be educated on the risks and benefits of opioids, and should be periodically evaluated by the prescribing physician.⁹ The CDC recommends using opioid therapy when treating patients with chronic pain in the following settings: cancer, palliative care, and end-of life.⁹ In the aforementioned patient presentations, the lowest effective dose should be used to alleviate a patient’s pain, in order to reduce the risk of opioid use disorder or overdose.⁹ Additionally, physicians should avoid the practice of prescribing long-acting opioids for chronic pain, as it is found that unintentional overdoses were twice as likely to occur in patients receiving long-acting vs short-acting opioids.⁹
4. Physicians should utilize and review a patient’s history of controlled substance prescriptions by utilizing the prescription drug monitoring program (PDMP), to determine if a patient is at risk of overdosing.⁹ PDMP date should be utilized when patients are initiating opioid therapy and periodically managing chronic pain.⁹ In the setting where patients are at risk of concurrent benzodiazepine or illicit drug abuse, routine urine drug testing can be implemented.⁹
5. Increased screening in the primary care setting, for patients with opioid addictions, should be conducted, via counseling, education, and motivational interviewing. Additionally, educating patients, their caregivers, and families on recognizing the signs of opioid overdose (non-responsiveness, decrease or cessation in respiration, and blueish discoloration of the fingertips or fingernails) and the need to immediately seek medical attention in this scenario should be conducted.^10-11 In conjunction with counseling, physicians can prescribe “take-home naloxone” and educate high-risk patients on the administration of this opioid-reversal agent.^10-11

Reference

• National Institute on Drug Abuse. Overdose death rates [Internet]. National Institute on Drug Abuse; 2018 [updated 2018 Aug; cited 2018 Sept 29]. Available from: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
• Centers for Disease Control and Prevention. Understanding the epidemic [Internet]. Atlanta: Centers for Disease Control and Prevention; 2017 [updated 2017 Aug 30; cited 2018 Sept 29]. Available from: https://www.cdc.gov/drugoverdose/epidemic/index.html
• World Health Organization. Management of substance abuse, information sheet on opioid overdose [Internet]. World Health Organization; 2018 [updated 2018 Aug; cited 2018 Sept 29]. Available from: http://www.who.int/substance_abuse/information-sheet/en/
• Strain E, Saxon AJ, Hermann R. Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis. UpToDate [Internet]. 2018 Aug [cited 2018 Sept 29]. Available from: https://www.uptodate.com/contents/opioid-use-disorder-epidemiology-pharmacology-clinical-manifestations-course-screening-assessment-and-diagnosis?search=opioid&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4
• Centers for Disease Control and Prevention. Opioid overdose: prescription opioids [Internet]. Atlanta: Centers for Disease Control and Prevention; 2017 [updated 2017 Aug 29; cited 2018 Sept 29]. Available from: https://www.cdc.gov/drugoverdose/opioids/prescribed.html
• Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med [Internet]. 2017 Sept [cited 2018 Sept 29]; 167: 293–301.Available from: http://annals.org/aim/fullarticle/2646632/prescription-opioid-use-misuse-use-disorders-u-s-adults-2015
• Kotalik J. Controlling pain and reducing misuse of opioids: ethical considerations. Can Fam Physician [Internet]. 2012 April [cited 2018 Sept 29]; 58(4): 381–385. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325448/
• Finestone HM, Juurlink DN, Power B, Gomes T, Rimlott N. Opioid prescribing is a surrogate for inadequate pain management resources. Can Fam Physician [Internet]. 2016 Jun [cited 2018 Sept 29]; 62(6): 465-468. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907548/
• Centers for Disease Control and Prevention. Opioid overdose: improve opioid prescribing [Internet]. Atlanta: Centers for Disease Control and Prevention; 2017 [updated 2017 Aug 30; cited 2018 Sept 29]. Available from: https://www.cdc.gov/drugoverdose/prevention/prescribing.html
• Katz M. Mitigating the dangers of opioids. JAMA Intern Med [Internet]. 2015 April [cited 2018 Sept 29]. Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2110991
• Coffin P, Saxon AJ, Herman R. Prevention of lethal opioid overdose in the community. UpToDate [Internet]. 2018 April [cited 2018 Sept 29]. Available from: https://www.uptodate.com/contents/prevention-of-lethal-opioid-overdose-in-the-community?topicRef=7804&source=see_link