Action requested: Be aware of guidance about appropriate prescribing of opioids for chronic pain and tools to help reduce diversion of drugs and to prevent overdose deaths. Consider certification to prescribe buprenorphine.
Background & Recommendations: Like the rest of the United States, Snohomish County is in the midst of an unprecedented epidemic of prescription opioid addiction and overdose associated with increased prescribing of opioids. CDC has issued a comprehensive evidence-based guideline for prescribing opioid medications for chronic pain (pain lasting longer than three months or past the time of normal tissue healing). The guideline is for primary care providers—who prescribe nearly half of all opioid prescriptions—treating adult patients for chronic pain in outpatient settings. Recommendations are not intended to guide treatment of patients in active cancer treatment, palliative care, or end-of-life care.
While prescription opioids can be part of pain management, they have serious risks. The new guideline aims to improve the safety of prescribing and reduce the harms associated with opioid use, including opioid use disorder and overdose. The guideline also focuses on increasing the use of other effective treatments available for chronic pain, such as non-opioid medications or non-pharmacologic therapies.
The guideline will help primary care physicians to determine if and when to start opioids to treat chronic pain, medication selection, dosage, duration, and when and how to reassess progress and discontinue medication. Providers and patients can use the guideline together to assess the benefits and risks of opioid use. You can find the complete guideline at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?s_cid=rr6501e1_e.
Among the twelve recommendations in the guideline, three principles are key to improving patient care:
- Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
- When opioids are used, the lowest possible effective dosage of immediate release opioids (rather than extended release/long acting opioids) should be prescribed to reduce risks of opioid use disorder and overdose.
- Providers should always exercise caution when prescribing opioids and monitor all patients closely.
Assuring that opioids are used appropriately is just one element of a comprehensive strategy to reduce opioid addiction and overdose. Removing unused opioids (and other drugs) from the home will reduce the potential for diversion of drugs to the street. To that end, please encourage patients to properly dispose of any unused medicines at secure drug take-back sites, not by flushing down the toilet or placing in the garbage (both of which contaminate the environment). A brochure listing Snohomish County locations is at http://www.snohd.org/Portals/0/Snohd/Waste/files/Medicine_Return_Brochure_2016_03_LML.pdf.
Treatment for addiction is another key element of a comprehensive strategy. Unfortunately, local treatment capacity is very limited. Medically assisted treatment is effective. A traditional approach using methadone can only be offered in special facilities, but a newer approach using buprenorphine (combined with naloxone as Suboxone) can be offered by primary care physicians who complete an eight-hour training. I urge all physicians who care for patients who have become addicted to opioids to consider becoming certified to prescribe buprenorphine. A listing of online trainings is at http://www.samhsa.gov/medication-assisted-treatment/training-resources/buprenorphine-physician-training. I will notify the medical community about local in-person trainings as I learn of them.
Finally, knowing that opioid addiction is a complex issue not easily prevented or treated, preventing overdose deaths is also important. Naloxone, which reverses opioid overdoses rapidly, is lifesaving. Local emergency medical services responders have long carried naloxone, but now our local firefighters and law enforcement officers also carry naloxone. The Health District is providing naloxone to people using Snohomish County’s syringe exchange. And through collaborative drug therapy agreements with the Health District, several local pharmacies can sell naloxone to anyone on request. A list of some of these pharmacies is at http://www.snohd.org/Diseases-Risks/Injection-Drug-Use.
You can find my recent health alerts posted on the Provider pages of our website, at http://www.snohd.org/Providers/Health-Alerts.