Cleaveland: Steps must be taken before using opiates

This is the third in a series of columns about the epidemic of opiate abuse in the U.S.

Pain cannot be measured. Both the pain sufferer and the caregiver must apply imprecise estimates to its intensity. For decades, severe and chronic pain was undertreated for fear of causing addiction to opiates. Caregivers worried that their licenses to practice would be endangered if medications they prescribed led to addiction in their patients.

Clif Cleaveland

In the 1990s, professional organizations re-evaluated their positions on treating pain. It became regarded as a "fifth vital sign" that had to be factored into the treatment. Morphine and other derivatives of opium were more widely used in the care of patients with active cancers. Opiates gained a valuable role in the care of persons who were dying or had intractable pain. Physicians gained specialized training in pain management and palliative care.

At this same time, more potent opiates were developed and aggressively marketed. Some new medications were available in extended-release tablets, which were supposed to give smooth relief from pain over many hours. The risk of addiction was minimized by the promoters of the new drugs, so inappropriate prescribing and misuse of the more powerful opiates led to sharp increases in deaths from overdose.

Data from the Centers for Disease Control and Prevention (CDC) show that, from 1999 to 2014, almost half a million Americans died from drug overdose. The majority of the deaths were attributed to prescription opiates - often used for non-medical purposes - and heroin. Forty-four Americans die each day from overdoses of medications prescribed for pain relief. The National Survey on Drug Use and Health estimates that almost 2 million Americans are addicted to prescription opiates. The average age for first- time use of these drugs is 21 years.

In response to this epidemic, the CDC issued new guidelines last month for safer, more appropriate use of opiates. The website - www.cdc.gov/drugoverdose/prescribing/guideline - contains invaluable information for providers and patients.

The recommendations are based upon an extensive review of published research which found little evidence of benefit and substantial risk of harm from long-term use of opiates in the treatment of chronic pain. The CDC also solicited input from major clinical organizations, including both primary-care and sub-specialty associations, experts in pain management and the public.

Central to the guidelines is a careful consideration of risks and benefits in prescribing an opiate. Patients must be active participants in the decision to use the drugs, and they should never be prescribed in a casual or kneejerk fashion.

Consideration should be given to physical therapy, massage, exercise and possibly cognitive psychotherapy as alternatives to medication. Non-opiates such as acetaminophen, ibuprofen and aspirin may provide control of painful symptoms. Depression may be a consequence or a contributor to chronic pain, leading to the addition of antidepressant medications or psychotherapy as part of a treatment program.

Because sustained-action opiates have a higher risk of addiction, immediate-release agents should be prescribed with the aim of using the smallest dose possible to control discomfort. If opiates are prescribed for acute pain caused by injury, dental work or other surgery, a short-term course limited to a few days should be prescribed.

When opiates are prescribed for chronic pain, a treatment plan with measurable goals should be formulated. Follow-up is vital, in one to four weeks initially and at regular intervals afterward. At each follow-up, the goals of therapy and the possibilities of side effects and drug dependence must be assessed. Caution should be used if the dosage is to be increased.

Certain medications such as benzodiazepines - Valium, Xanax, Ativan - should not be used alongside opiates if at all possible. Alcohol poses another risk.

Patients who become dependent upon opiates should not be abandoned but should be guided into carefully supervised treatment programs which health insurance programs need to support.

Pain management needs to be incorporated into training programs for all caregivers who will be engaged in the management of patients with acute or chronic pain. Post-graduate updates are important for caregivers already in practice.

Persons suffering from acute or chronic pain should ask questions about the risks and benefits of any medication prescribed. Are there alternatives to an opiate if one is being prescribed? An opiate should not be used until all other medications currently taken are identified and deemed compatible.

Persons experiencing pain should not accept a pill promoted for pain relief from another person, including trainers for athletic teams.

Opiates have an important place in medical therapy, but these drugs are currently overused with dangerous consequences. Their use cannot be casual. They should only be prescribed by a skilled caregiver who has taken a careful history and engaged the patient in a discussion of the drug under consideration. Careful follow-up is essential.

Read the complete CDC guidelines. They can be lifesavers.

Contact Clif Cleaveland at ccleaveland@timesfreepress.com.