Heightened alarm over opioid use

New guidelines issued in March by the CDC emphasize once again the devastating impact of opioid use, which claimed nearly 29,000 lives in 2014 and more than 165,000 lives over the past 15 years.

Deaths related to drugs have surged across the country, but opioids continue to be used widely. The CDC reports that in 2013 alone, nearly 1.9 million people in the U.S. abused or were dependent on prescribed opioid medication.

More startling yet, opioids were prescribed, and continue to be prescribed widely, despite the lack of clear evidence they are superior to other therapies. "It has become increasingly clear that opioids carry substantial risk but only uncertain benefits - especially compared with other treatments for chronic pain," says CDC director Dr. Thomas Frieden.

The agency's latest guidelines are directed at prescribing physicians, who are often uneasy about managing patients with chronic pain and feel they don’t have enough training in prescribing opioids. "Of primary importance, non-opioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks," the guidelines state.

"Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. Clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible," the guidelines add.

 
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Knowledgeable observers say the guidelines are significant because they will eventually be seen as the definition of the standard of care, thereby influencing physicians and how insurers determine reimbursement. Dr. Andrew Kolodny, head of Physicians for Responsible Opioid Prescribing, noted to the New York Times the guidelines are one of the most significant interventions by the federal government.

"This is the first time the federal government is communicating clearly to the medical community that long-term use for common conditions is inappropriate," he said.

The guidelines are of particular interest to the workers' compensation community. "The use of opioids is by far the most controversial and risky kind of care in workers' comp. In direct and indirect ways, opioids are more risky and costly than all other controversial forms of care combined," concludes an in-depth report by Comp Pharma. a national organization comprised of the industry's leading workers' compensation pharmacy benefit managers.

The report notes that although there has been a shift in thinking in medical circles in recent years, and prescriptions for opioid use in workers' comp appear to have declined in recent years, it can take more than 15 years for physicians generally to adopt a best practice after a best practice is set.

Some reports suggest that although the number of opioid prescriptions has declined, the dosage per prescription may not have declined. Earlier studies have documented that the average dose per prescription for OxyContin and Vicodin increased between 2000 and 2010.


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