Opioid medications include Morphine, MS Contin, Percocet (oxycodone), Vicodin (hydrocodone), Dilaudid (hydromorphone), Oxycontin, Tylenol #3, and the list goes on.
These medications are essential for treatment of pain after many injuries and surgeries. Management of pain is a central part of patient care. Yet these medications are also some of the most commonly abused prescription drugs. There is a fine balance between controlling pain and over medicating someone to the point of providing euphoria. Opioid prescription abuse has been a hot topic for over two decades, yet there have been limited solutions to the problem due to the complicated clinical situation.
Here are some important considerations:
1) The United States prescribes 80% of the worlds opioid medications although it treats <5% of the worlds population. The United States about 27,400,000 grams of hydrocodone annually compared with 3,237,000 grams for Great Britain, France, Germany, and Italy combined. The recent growth of Pain Clinics, which provide long-term access to opioids in patients with chronic pain conditions, may be one of the important underlying causes. Interestingly, despite the dramatic rise in opioid medication use, there has not be a corresponding rise in other pain medications like tylenol, or anti-inflammatory medications. Yet some of this is cultural. One study compared pain medication prescriptions for common orthopedic injuries in the US and Netherlands. Looking at patients with broken hips, in the United States, 85% received a prescription for opioids on discharge, while 0% received this in the Netherlands. Looking at patients with broken ankles, in the United States 84% received a prescription for opioids on discharge, while 6% received this in the Netherlands.
2) The majority of opioid medications are classified as Schedule II and III drugs (based on the Controlled Substances Act of 1970). These are considered to have a high risk for abuse and dependence.
3) Opioid abuse has increased 300% in the last decade. Unintentional overdose deaths have increased 125% in the last decade and now account for more deaths than heroin and cocaine combined.
4) Opioid abuse is estimated to cost >$50 Billion every year due to missed work and criminal costs, and hospitalizations.
5) Opioid medication is not an effective long term treatment for injuries. Patients who continue to use opioids 1 month to 2 months beyond the time of surgery have more psychological distress, worse coping strategies, worse symptoms, and longer disability irrespective of injury type or surgery type .
We want to review an important topic recently covered by the AAJOS (see article).
1. The opioid epidemic: impact on orthopaedic surgery. Morris BJ, Mir HR. J Am Acad Orthop Surg. 2015 May;23(5):
2. Opioid epidemic in the United States. Manchikanti L et al. Pain Physician. (2012)
3. Urine drug testing: current recommendations and best practices. Owen GT, Burton AW, Schade CM, Passik S. Pain Physician. 2012
4. Association between opioid prescribing patterns and opioid overdose-related deaths. Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow FC. JAMA. 2011 Apr 6;305(13):1315-21.
5. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, Kruszewski SP, Alexander GC. Med Care. 2013 Oct;51(10):870-8.
6. Associations between pain clinic density and distributions of opioid pain relievers, drug-related deaths, hospitalizations, emergency department visits, and neonatal abstinence syndrome in Florida. Sauber-Schatz EK, Mack KA, Diekman ST, Paulozzi LJ. Drug Alcohol Depend. 2013 Nov 1;133(1):161-6.
7. Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. Helmerhorst GT, Vranceanu AM, Vrahas M, Smith M, Ring D. J Bone Joint Surg Am. 2014 Mar 19;96(6):495-9.