When Steven Passik, PhD, slipped on the ice earlier this year and tore his supraspinatus tendon, he needed rotary cuff surgery and was given a prescription for opioids to deal with the pain — no questions asked.
“They didn’t ask me who I am or what I do; they didn’t ask me a single question about my risk for opioid abuse,” said Dr. Passik, vice president, research, Millennium Health, a company based in San Diego, California, that provides urine and pharmacogenetic testing.
His doctor probably felt that aggressive pain management is the humane approach to postoperative pain, said Dr. Passik. “But the pain goes on for 2 to 3 months and 2 to 3 months is not a trivial exposure in people with risk factors. There’s nothing humane about giving out opioids without necessarily understanding what risk you’re exposing a person to.”
This, said Dr. Passik, epitomizes part of the problem of prescription opioid misuse, abuse, diversion, and overdose across the country.
“The point is, what happened to me is not the exception; it’s the rule,” he said. “Thousands and thousands of shoulders and knees and all kinds of surgeries are being done and opioids are given out with no risk assessment.”
Dr. Passik addressed delegates during a keynote presentation here during PAINWeek.
The way he sees it, physicians should still provide opioids for pain relief but they should be stratifying patients for their risks before reaching for their prescription pads. “Patients should be looked at for the known risk factors for drug abuse: younger age, male gender, comorbid psychiatric problems, a history of substance abuse, a family history of substance abuse, a history of smoking,” as well as other relevant social and psychological factors, Dr. Passik said.
“Doctors should assess each patient, figure out where they lie on a continuum of risk, and then implement a program that helps keep them safe.”
The 22-year-old guy with a drinking problem may raise some red flags, while the little old lady with arthritis may not, he said. But doctors shouldn’t make assumptions, added Dr. Passik. Although 85% of addictions are manifested by age 35 years, leaving seniors at relatively low risk for addiction, a risk assessment should still be in order at any age.
As well as stratifying risks, doctors should use the tools they have available to them, such as abuse-deterrent opioids, lock boxes, safer packaging, government-run prescription monitoring programs that identify people accessing multiple prescribers, and state-of-the-art urine drug testing that can now deliver results in 24 to 48 hours.
How often a patient gets drug tests would depend on where on the risk continuum a patient lies, said Dr. Passik. For example, a higher-risk patient might get tested every visit and a less risky 1 every 6 months.
He pointed to the Project Lazarus, a public health program in Wilkes County, North Carolina, as a model of how communities have successfully tackled the problem of drug overdose deaths. The nonprofit project provides assistance to create and maintain community coalitions, helps create local drug overdose prevention programs, and educates health providers on appropriate opioid use.
“At the end of the day, one of the most important things about Project Lazarus was that they were able to dramatically reduce opioid overdoses without dramatically reducing opioid prescribing,” said Dr. Passik.
“The focus had been on access to the drugs as opposed to getting the drug to the people who needed and having the safeguards in place to keep them safe.”
Not Enough Time
Dr. Passik places much of the blame for the current opioid woes firmly on the healthcare system. “I’ve always felt that the problem was that we took opioids and put them into a healthcare system that has a hard time giving doctors enough time to assess people” or reimbursing them properly, Dr. Passik said.
“When you introduce opioids into an 8-minute visit once a month with minimal follow-up, which has been the primary care model, it’s a recipe for a public health disaster.”
Much of the buzz at this pain meeting is on the increasing use of relatively inexpensive heroin as a replacement for prescription opioids that have become harder to come by. And with this increase comes more and more heroin overdoses.
Dr. Passik had a long list of statistics illustrating this. For example, in Ocean County, Florida, there were 52 fatal overdose from January to May of 2014, 1 fewer than in all of 2012. In New Jersey, there were 368 deaths related to heroin in 2011, up from 287 deaths in 2010.
A 2012 National Survey on Drug Use and Health found that about 669,000 Americans over age 12 years had used heroin at some point in the year. Roughly 467,000 were considered heroin-dependent, which is double the number for 2002.
But Dr. Passik isn’t convinced that those turning to heroin are patients who in the past treated their chronic pain with opioids. “The connection between having chronic pain, being treated with opioids and ending up on heroin has been talked about, but I’m not sure we know exactly who those people are.”
He believes that the surge in heroin use may be mainly among the mostly young people who were abusing opioids — getting them from friends and family, stealing them, or buying them on the street.
Now several months after his shoulder surgery, Dr. Passik is almost mended. He used the opioids to manage the pain until he was at the point where, as he said, “regularity was more important than a couple of hours of pain relief,” and he switched over to nonopioid pain relievers.
In a separate presentation here, according to research carried out in part by Sean Mackey, MD, PhD, chief, Division of Pain Medicine, Stanford University, Palo Alto, California, and president of the American Academy of Pain Medicine, risk factors for abuse include preoperative opioid use, greater self-perceived risk for addiction, and more depressive symptoms.
“The severity of pain and pain duration didn’t predict the use of opioids at all in our models; it was the psychological factors,” Dr. Mackey told delegates during his presentation on the psychology of opioids.
In fact, said Dr. Mackey, there’s emerging evidence that self-loathing is the biggest factor predicting prolonged opioid use after surgery.