Prescription painkillers' overuse has become 'silent epidemic': NIH

In 2012, Americans received nearly 260 million prescriptions for opiate painkillers. Now, the National Institutes of Health (NIH) has released a white paper that reports “a dire need for research” to make up for the “scant” evidence that opioid painkillers should be used to treat chronic pain.

The NIH white paper condenses the final work of a seven-member panel that was convened in September to study the place of opioids in medicine. That panel, comprising independent experts in psychiatry, epidemiology and other disciplines, wrote in its full report that “the prevalence of chronic pain and the increasing use of opioids have created a ‘silent epidemic’.”

“The overriding question,” the panel wrote, “is whether we, as a nation, are currently approaching chronic pain in the best possible manner that maximizes effectiveness and minimizes harm.”

There is not nearly enough good research to say for sure, the experts said, writing: “Evidence is insufficient for every clinical decision that a provider needs to make about the use of opioids for chronic pain.”

That dearth of evidence combined with high numbers of substance abuse and overdose deaths in the US have created circumstances doctors need to confront immediately, the authors said.

Related: Most US patients on opiate painkillers prescribed dangerous drug cocktails

By 2010, there were more than 160,000 hospitalizations a year for prescription opioid addiction. In 2012, healthcare providers wrote 259 million prescriptions for opioids​, according to the ​Centers for Disease Control and Prevention (CDC). That year, more people aged 25 to 64 died from overdoses than car accidents.

The next year, 2013, the agency found that 71% of overdoses from prescription drugs – a total of 16,325 deaths – were caused by opioid painkillers. Last year, the CDC reported that doctors were a primary source of drugs for opioid abusers, and a doctor at the CDC estimated that 46 Americans died every day from overdoses of prescription painkillers.

Oxycodone, codeine, dilaudid and methadone are among the opiates most frequently abused; morphine is also often prescribed for patients who report extreme pain.

The new NIH white paper estimates that between five and eight million Americans take opioid painkillers to manage chronic long-term pain, but nearly all opiate drugs consumed for months and years were approved on the basis of 12-week studies.

Although people have consumed opioids to dull short-term pain for centuries, new research shows there are distinct kinds of physical pain, and that not all treatments work as effectively to manage them. The panel found that patients with chronic pain were too often “lumped into a single category”, even though humans have three distinct pain mechanisms, such as those caused by inflammation versus nerve damage or arthritis and cancer.

Healthcare providers also proved ill-prepared or unwilling in many cases to confront patients’ personal histories, which the panel emphasized can have an outsize effect on a person’s risk for addiction. Depression, anxiety, past substance abuse, genetics, quality of life and concurrent illness are all listed as important points for a provider to consider before prescribing an opioid.

But experts told the panel almost unanimously that they feared physicians could not distinguish between people who were at risk or could be at risk to develop problems with misuse.

The health system itself encourages doctors to prescribe drugs, the panel noted, since many plans “nonopioid alternatives as second- or third-line options rather than placing them more appropriately as first-line therapy”.

“Important clinical tasks” have fallen by the wayside, the experts warned, in favor of seemingly easy answers such as prescriptions.

“In the case of pain management, which often requires substantial face-to-face time, quicker alternatives have become the default option.”

Ultimately, the NIH panel recommended that providers tailor treatment to each individual patient, and suggested “a multidisciplinary approach”, including a mix of physical therapy and non-drug options, “similar to that recommended for other chronic complex illnesses, such as depression, dementia, eating disorders or diabetes”.

Opioids can be very effective for some patients, the experts acknowledged, but even for those for whom the drugs work the panel recommended regular check-ups.

There is “a dire need for research on the effectiveness and safety of opioids”, the panel wrote, while also recommending an overhaul of the electronic health record system to better help doctors keep track of a patient’s medical history.

On Wednesday, a study published in the New England Journal of Medicine suggested that prescription opioid misuse in the US is gradually decreasing , in part thanks to laws and tracking systems were instituted during the peak of prescription drug abuse in 2010-11.

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