Opioid-related morbidity and mortality: What every physician should know

Troy Parks
Staff Writer
AMA Wire
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A new educational module incorporates animation, infographics and storytelling to explain what led to the opioid overdose epidemic and how opioid misuse is linked to heroin addiction. The module also outlines simple steps that can be taken to reduce harms when considering the use of opioids in patients experiencing pain.

In addition to offering continuing medical education (CME) credit, the new module  explains the impact of opioid prescription trends over the past two decades, patient risk factors for opioid misuse, the variables that increase risk of unintentional overdose, the association between opioid misuse and heroin use or addiction, details of the latest guidelines and basic approaches to reduce opioid-related harm in patients.

A medical history of the opioid epidemic

“The large increase in opioid prescribing over the last two decades has occurred against the backdrop of various population estimates of the burden of chronic pain in the U.S.,” the module says. About 100 million American adults suffer from chronic-pain conditions, according to the Institute of Medicine report, “Relieving Pain in America.” And more than one-quarter of adults said they have experienced low back pain.

During that same time period, growing numbers of patients with chronic, non-cancer pain were offered long-term opioid therapy. The change in prescribing behavior has been influenced by several competing interests.

In the 1980s and early 1990s, physicians devoted more attention to improving the management of cancer pain and post-surgical pain. “Undertreatment of pain was recognized and the aggressive use of opioid analgesics was endorsed as an effective approach,” the module says. “With the advent of a new array of extended-release and long-acting prescription opioid products and aggressive pharmaceutical marketing, opioid treatment was extended to patients with chronic, non-cancer pain, despite lack of evidence obtained from long-term, randomized, controlled trials.”

Promulgation of pain as the fifth vital sign and the evolution of patient-satisfaction surveys that include a focus on the extent to which a patient’s pain is relieved also encouraged the expanded use of opioids. The module describes other factors that also contributed to a practice environment that promoted routine opioid use for pain management, including:

  • Inadequate training across the continuum of medical education in pain management and the diagnosis and treatment of substance-use disorders
  • A lack of access to multimodal pain care, including non-pharmacologic approaches to pain management and access to mental health care for comorbid conditions
  • Limited and inadequate payment for non-pharmacological approaches to pain management

Treatment admissions for opioid-use disorder have increased, and the death rate from prescription opioids leveled off somewhat between 2007 and 2013. But during the same time frame, heroin-related overdoses and deaths also rose. That is a trend largely driven by increased use of heroin and illicit fentanyl, which can be cheaper to obtain than prescription opioids by individuals with opioid-use disorder.

A patient-centered strategy

Every patient is different. And not all patients experience the same level or type of pain. Developing a comprehensive, population health-level strategy for pain management is important, but conceptually there are several things to consider when managing a patient with chronic pain.

Effective pain management demands a multimodal assessment and treatment plan that identifies and addresses all components of the individual’s pain experience, the module says. The module provides steps and strategies to help physicians safely prescribe opioid medications  for  patients with acute or chronic pain.

The module is available on the AMA Education Center, along with another module that takes a more in-depth look at safe opioid prescribing for chronic pain. Both modules are free.

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