Sadly, like many other states, Pennsylvania has experienced an alarming rise in drug overdose deaths, and its overdose death rate is more than twice the national average. In fact, more deaths now occur as a result of overdosing on prescription opioids than from all other drug overdoses combined, including heroin and cocaine. “The Office of the Attorney General arrests on average more than four drug dealers a day," Attorney General Josh Shapiro said in a statement. "Our arrests of medical personnel and others for illegally diverting prescription drugs are up 72 percent. Our national investigation with 41 attorneys general of the pharmaceutical industry and the opioid painkillers fueling this epidemic is ongoing and active." The opioid epidemic is tied closely to another epidemic in our country, that of chronic pain—although the ties are very complex.
Opioid prescribing for chronic nonterminal pain has increased in recent years, although evidence for its long-term effectiveness is weak and its potential for harm is significant. The Agency for Healthcare Research and Quality reviewed studies on the effectiveness and risks of long-term opioid treatment of chronic pain. The results are eye-opening: No randomized trials or comparative observational studies meeting the reviewers’ criteria were found that addressed opioids’ effectiveness for chronic pain or comparing their effectiveness to other treatments, making it impossible to know whether long-term treatment with opioids adequately addresses patients’ symptoms or improves their functioning or quality of life. At best there was weak evidence regarding optimal dosing strategies with these medications.
According to Governor Wolf’s administration, “proper treatment of chronic pain includes an interdisciplinary and multi-model approach that is tailored to help the patient control pain and relieve suffering.” Specific treatment options should be based on best evidence whenever possible.
People who experience chronic pain should know and have discussions with their physicians and family concerning alternatives to opioid therapies. For instance, there are non-opioid medications such as acetaminophen, non-steroidal anti-inflammatory medications, anti-seizure medications, and local anesthetics. In addition, there is growing interest in the use of cannabinoids for the treatment of a variety of chronic pain conditions. Cognitive-behavioral therapy and mindfulness- based therapy can provide improved symptom control, physical functioning, adaptive coping and self-efficacy. Moreover, treatment of comorbid depression and anxiety can improve biopsychosocial functioning. Physical therapy, including aquatic therapy, and massage therapy can be a critical component in improving pain control and physical functioning in most patients. Even supportive modalities such as yoga and Tai Chi may be very effective in improving pain and physical functioning in some patients. Interventional therapy, such as epidural steroid injections, radiofrequency procedures and spinal cord stimulation, can also provide effective pain relief in patients experiencing specific pain disorders.
Pennsylvania has established 11 prescribing guidelines for health care providers including:
- Worker’s Compensation Prescribing Guidelines;
- Treating Chronic Non-Cancer Pain;
- Emergency Department Pain Treatment Guidelines;
- Opioids in Dental Practice;
- Opioid Dispensing Guidelines;
- Obstetrics and Gynecology Opioid Prescribing Guidelines;
- Geriatric Pain;
- Use of Addiction Treatment Medications in the Treatment of Pregnant Patients with Opioid-Use Disorder;
- Safe Prescribing Benzodiazepines for Acute Treatment of Anxiety and Insomnia;
- Safe Prescribing Guidelines for Orthopedics and Sports Medicine; and
- Safe Prescribing of Opioids in Pediatric and Adolescent Populations.
The following guidelines address the use of opioid pain medication for chronic noncancer pain. They are intended to help healthcare providers improve patient outcomes and to supplement, but not replace, the individual provider’s clinical judgment.
1. Before initiating chronic opioid therapy, clinicians should conduct and document a history that includes a detailed review of the patient's pain experience, including assessment for co-existing: depression, anxiety disorders and sleep disorders; past and current substance use disorder, as well as risk assessment for development of aberrant drug-related behavior following chronic opioid administration. Evaluation should include assessment for conditions that increase the risk of harm from chronic opioid administration, including sleep-disordered breathing, pulmonary disease, and concurrent use of centrally-acting sedating medications.
2. Appropriate testing to confirm the underlying diagnosis should be completed before starting chronic opioid therapy.
3. A urine drug screen should be obtained and reviewed before initiating chronic opioid therapy. In addition, Pennsylvania state law requires clinicians to obtain and review a report from the Prescription Drug Monitoring Program (PDMP) before prescribing all controlled substances. Care should be taken to obtain PDMP data from all relevant states, which usually can be accomplished through the Pennsylvania PDMP program.
4. Medical records from past health care, including the results of relevant laboratory and radiological studies, should be obtained and reviewed, as they often are a valuable source of information regarding past care, including response to medications, specifically opioids.
5. The initial patient evaluation should include documentation of a diagnosis, treatment plan and goals of therapy. Goals of therapy should be specific and measurable, and should be integrated into ongoing patient monitoring throughout treatment.
To view the Guidelines for Initiation, Continuation and Discontinuance of Opioid Therapy, click here.
While not specifically referenced in above referenced guidelines, health care professionals should consider encouraging patients with chronic pain being managed by opioids to include their family members in their treatment plans, as valuable information can be gleaned from these sources that may improve the treatment plan, and therapeutic outcomes.
For more information on the above topics, check out these links: