Community – outpatient setting

Opioid analgesics are an important tool for the management of chronic pain in the outpatient and community settings. These include hydrocodone, oxycodone, morphine and codeine. Due in part to a recognition that chronic pain was often inadequately managed in the past,  prescriptions for and use of these drugs has escalated in recent years and these drugs frequently diverted for improper use.

Opioid misuse is epidemic

Opioid Facts
  • Since 1999, sales of prescription opioids have quadrupled
  • 1 out of 5 patients with non-cancer pain or related disease are prescribed opioids
  • In 2014, nearly 2 million Americans abused or were dependent on prescription opioids
  • From 1995 to 2014, more than 165,000 people died for overdose related to prescription opioids
Source CDC

While many people benefit from using opioids to manage pain, prescription drugs are frequently diverted for improper use. In the 2013 and 2014 National Survey on Drug Use and Health (NSDUH), 50.5% of people who misused prescription painkillers got them from a friend or relative for free, and 22.1% got them from a doctor. According to the National Survey on Drug Use and Health (NSDUH) – 2014 (PDF | 3.4 MB), 1.4 million people used prescription painkillers non-medically for the first time in the past year.

As people use opioids repeatedly their tolerance increases and they may not be able to maintain the source for the drugs. This can cause them to turn to the black market for these drugs and even switch from prescription drugs to cheaper and more risky substitutes like heroin.

A recent study of office-based physician visits found that opioids were prescribed almost twice as often as a decade previously. Physicians prescribed opioids in almost 20 percent of visits for pain with prescribing rates increasing more for family practice, general medicine, and internal medicine compared to other specialties. In 2012, healthcare providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the U.S. to have a bottle of pills.

Escalating opioid deaths hit record numbers

Opioids deaths chart2According to the CDC, overdose deaths
involving prescription opioids have quadrupled since 1999 and so have sales of these prescription drugs.2 From 1999 to 2014, more than 165,000 people have died in the U.S. from overdoses related to prescription opioids with nearly 80 dying every day from an opioid overdose.

Overprescribing of opioids after surgery adds to the problem

Opioids have been used for centuries and remain the most potent and reliable analgesic agents used routinely and effectively for the treatment of acute severe pain following trauma, extensive burns or major surgery.  The concern and dilemma for prescribing clinicians is with their use for chronic non-malignant pain because of their potential for abuse and addiction.

Two recent studies suggest that opioids might be over-prescribed for pain after dental and other types of lower risk surgery.  In a large study of over 2.7 million Medicaid patients, a disproportionately large amount of opioids were prescribed after tooth extraction, given the expected intensity and duration of post-extraction pain. In this study, 42 percent filled a prescription for an opioid pain medication within 7 days of a tooth extraction and opioids were dispensed more often (61 percent) for teens aged 14 to 17 (JAMA 2016).

A similar study looked at opioid prescribing for 14 million patients who had surgery for carpal tunnel syndrome, gall bladder removal, hernia repair or knee arthroscopy. Eighty percent of those patients filled a prescription for an opioid pain medication within 7 days of being discharged from the hospital (JAMA 2016).  Prescribing guidelines in a recent CDC Guideline released in March 2016 state that acute pain “can often be managed without opioids” and suggest that “three days or less will often be sufficient; more than 7 days will rarely be needed.”

Options for post-operative pain

American Pain Society recently released guidelines that suggest a multi-modal approach to treatment of post-operative pain that includes a multi-modal approach that can be used along with opioids if needed.  For example, it might include a combination of non-opioid medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), regional anesthesia (e.g., nerve blocks) and other approaches (e.g., passive motion, pre-operative education on options for pain management). This approach will help reduce the risk of post-discharge long term use, dependence and addiction.

Additional info

For more information, visit our section on safe opioid use in the in-patient setting and visit our resource section for additional tools and guidelines.