Prescription Opioids: The Real Story 4/30/15
Don Teater MD Medical Advisor National Safety Council Masters student at the UNC Gillings School of Global Public Health
Don Teater MD Disclaimer: The information that I am presenting is my own opinion (based on a large amount of research). It is not the opinion of the National Safety Council. I receive no funding from any organization or individual other than NSC.
Opioid increase Drug distribution through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of >600%. Centers for Disease Control and Prevention. CDC grand rounds: Prescription drug overdoses a U.S. epidemic. MMWR Morb Mortal Wkly Rep 2012; 61:10-13
The State of US Health Years lived with disability (in thousands) 3500 3000 2500 2000 1500 1000 1990 2010 500 0 Low back pain Other MS disease Neck pain Osteoarthritis Murray, C. (2013). The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA : The Journal of the American Medical Association, 310(6), 591 608.
Institute of Medicine Relieving Pain in America 2011 Pain affects millions of Americans; contributes greatly to national rates of morbidity, mortality, and disability; and is rising in prevalence. IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.
Rates of opioid overdose deaths, sales and treatment admissions, US, 1999-2010 8 Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000 7 6 5 Rate 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year National Vital Statistics System, DEA s Automation of Reports and Consolidated Orders System, SAMHSA s TEDS
Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. International Association for the Treatment of Pain
Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. International Association for the Treatment of Pain
Acute pain: treatment Acetaminophen Tylenol NSAIDS Ibuprofen, naproxen, diclofenac, Celebrex, many others. Opioids Morphine, oxycodone, hydrocodone, fentanyl, heroin. Topical agents
Acetaminophen Pros: Analgesic Antipyretic Oral and IV Minimal GI side-effects NNT is 3.5 for 500 mg for 50% pain relief Cons No anti-inflammatory properties Toms, L., Hj, M., Derry, S., & Ra, M. (2008). Single dose oral paracetamol ( acetaminophen ) for postoperative pain in adults. Cochrane Database of Systematic Reviews, (4). doi:10.1002/14651858.cd004602.pub2
Pros: Analgesic Antipyretic Anti-inflammatory Oral, IM and IV NNT for 50% pain relief Cons: Ibuprofen 200 mg: 2.7 Side effects: GI Renal Cardiac NSAIDs
Pros Opioids Analgesic Oral, IM and IV NNT (morphine 10 mg IM) = 2.9 Cons Mentally impairing Delay recovery Increase medical costs Opioid hyperalgesia Double the chance of disability Increase falls Cardiac, GI? Addiction
Efficacy of pain mediations 70 Percent with 50% pain relief (beyond placebo) 60 50 40 30 20 10 0 Ibuprofen 200 mg Acetaminophen 500 mg Ibuprofen 400 mg Oxycodone 15 mg Oxy 10 + acet 1000 Ibu 200 + acet 500 Percent with 50% pain relief
Renal colic A 2005 Cochran review concluded: NSAID medications and opioids have equal effectiveness in treatment of acute renal colic but opioids have more side-effects. Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDS) versus opioids for acute renal colic. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004137. DOI: 10.1002/14651858.CD004137.pub3.
Chronic pain No evidence that opioids are effective for long-term treatment of chronic pain. Safe and effective use of opioids for chronic pain is an invalid concept. No evidence that these can be used safely No evidence that they can be used effectively Epidemiologic studies have shown that those on chronic opioid therapy have worse quality of life than those with chronic pain who are not 1. (1) Eriksen, J., Sjøgren, P., Bruera, E., Ekholm, O., & Rasmussen, N. K. (2006). Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain, 125(1-2), 172 9. doi:10.1016/j.pain.2006.06.009
125,000 Number of deaths in the last decade from opioids. More than twice the number of American deaths in the Vietnam war Medical and dental community are the vector This epidemic is completely reversible with a change of behavior that will result in better pain management
Culture of Safety As you discuss programs and policy to prevent prescription drug problems, you are NOT weighing the appropriate treatment of pain against public health. Reducing opioid prescribing will improve the treatment of pain and reduce abuse, addiction and overdose. We must develop innovative ways to get the culture of safety into physician and dental offices.
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To write prescriptions is easy, but to come to an understanding with people is hard. -- Franz Kafka, A Country Doctor
Don Teater MD don.teater@nsc.org White papers Evidence on the efficacy of pain medications: nsc.org/painmedevidence The Psychological and Physical Side Effects of Pain Medications: safety.nsc.org/sideeffects