Public Health and Prevention of Opioid Misuse

LAS VEGAS—The United States is currently in the midst of an opioid epidemic, which has been recognized as a public health crisis by clinicians, scientific bodies, and the government. Much effort is now being devoted to understanding the issues underpinning this phenomenon and devising strategies to tackle it.

The release earlier this year by the US Centers for Disease Control and Prevention (CDC) of a “Guideline for Prescribing Opioids for Chronic Pain” has had a profound impact on attitudes of clinicians toward opioid prescribing.¹

In light of these developments, Beth Darnall, PhD, clinical associate professor and Clinical Pain Advisor board member, and Sean C. Mackey, MD, PhD, Redlich Professor, both at Stanford University Medical Center, co-presented a lecture at PAINWeek 2016 in an endeavor to shed some light on the opioid epidemic, the CDC guideline, and the National Pain Strategy that outlines “the federal government’s first coordinated plan for reducing the burden of chronic pain.”^2,3

With this lecture, Dr Mackey and Dr Darnall sought to explain the public health approach to the problem of prescription opioid-related deaths, present pain psychology as an essential component of chronic pain management, and describe the role of this approach in the treatment of both acute and chronic pain.

In addressing opioid misuse, Dr Mackey said 4 steps are key: 1. defining the problem; 2. identifying risks and prevention factors; 3. developing and testing prevention strategies; and 4. ensuring widespread adoption.

An unfortunate consequence of the CDC guideline, according to Dr Mackey, is that “patients on opioids [are] increasingly being ‘dumped’ by physicians.” In addition, physicians have growing concerns about prescribing opioids, sometimes refusing to do so, behavior that leads to a certain stigmatization of patients and a struggle to find adequate care.

The link between pain, emotions, and cognition, consisting of feedback loops between these 3 entities, is well established.⁴ In addition, nociception can trigger catastrophizing and pain hypervigilance, resulting in an amplification of pain. In “affectively dysregulated” patients, associative learning may occur between recurrent opioid use and negative emotions.⁵

Using low back pain and surgical pain as examples, Dr Mackey presented some of the risk and prevention factors for both persistent opioid use and chronic pain—these include pain catastrophizing, the single best predictor of opioid use; anxiety; and depression.⁶

Depressive factors dramatically increased risk for long-term opioid use.Those individuals with a higher self-perceived risk of addiction remained on opioids the longest. What Dr Mackey refers to as “self-loathing,” the depressive symptoms with a stronger cognitive component, was the highest predictor for prolonged opioid use.⁷

Larger-scale population studies have also been conducted utilizing private insurer databases to determine postoperative opioid use in opioid-naive patients.⁸ Surgery and the type of surgery—in particular, total knee arthroplasty and cholecystectomy—convey risk of opioid use.⁹

A major challenge to pain management is that the processes underpinning pain are highly complex. In addition, populations used in randomized controlled trials are homogeneous, and approximately 90% of patients are screened out of those trials.

“The problem is that “those 90% represent the real world. The 10% we take in do not represent anything like who we care for,” Dr Mackey said. Many medications are “put into the wild for a population that was not studied.”

This realization has led to calls by both the Institute of Medicine and the National Institutes of Health for “improved data on pain and opioids, and for the development of learning healthcare systems that allow us to integrate that knowledge and combine science, informatics, and culture to improve the quality of care,” added Dr Mackey.

“Ultimately, the goal is to turn our clinics into research laboratories where every single patient is characterized,” noted Dr Mackey.

References

1. CD . CDC Guideline for prescribing opioids for chronic pain—United States, 2016. Available at: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Accessed September 8, 2016.
2. Darnall B, Mackey S. In the wake of the CDC Opioid Guideline and the National Pain Strategy: leveraging pain psychology and platforms to address the national pain and opioid crises. Presented at: PAINWeek 2016. Las Vegas, NV; September 6-10, 2016.
3. US Department of Health and Human Services. The National Pain Strategy. Available at: https://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm. Accessed September 8, 2016.
4. Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci. 2013;14(7):502-511.
5. Andrzejewski ME, Mckee BL, Baldwin AE, Burns L, Hernandez P. The clinical relevance of neuroplasticity in corticostriatal networks during operant learning. Neurosci Biobehav Rev. 2013;37(9 Pt A):2071-2080.
6. Carroll IR, Hah JM, Barelka PL, et al. Pain duration and resolution following surgery: an inception cohort study. Pain Med. 2015;16(12):2386-2396.
7. Hah JM, Mackey S, Barelka PL, et al. Self-loathing aspects of depression reduce postoperative opioid cessation rate. Pain Med. 2014;15(6):954-964.
8. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-1293.

Follow @ClinicalPainAdv