6
doc • Spring 2016
Kentucky
Recent Federal Guideline And Marketing
Changes In Opioid Prescription Policy
By Robert P. Granacher,
Jr., MD, MBA
Larochelle et al. (2016)
published research on
2,848 commercially insured
patients, with ages between
18 and 64 years, who sustained a nonfatal
opioid overdose during long-term opioid
therapy for non-cancer pain between May
2000 and December 2012. Patients were
followed over a median time interval of 299
days. Physicians re-dispensed opioids to 91%
of patients after they had made a potentially
fatal overdose. Two hundred and twelve
patients had a second or third opioid overdose after being prescribed more opioids.
After two years follow-up, the repeated overdose rate was 17% for patients receiving high
doses of opioids after the index overdose.
One just can’t make this stuff up.
Unbelievably, almost all patients continued
to obtain prescription opioids from their
clinicians after they had made a potentially
fatal overdose. This article further noted that
research demonstrates that after an overdose,
opioid discontinuation reduces risk for
repeated overdoses.
With regard to Kentucky, in 2013, there
were 1,019 resident drug overdose deaths.
This was a slight decrease from the prior high
point in 2012. This placed Kentucky second
among all states in our country for resident
age-adjusted drug overdose death due to
opioids (23.7/100,000). Of the more than
1,000 opioid overdose deaths, pharmaceutical opioids remained the primary cause of
death, according to medical examiners. In
2013, pharmaceutical opioids were causally involved in 438 drug overdose deaths in
Kentucky. Kentucky overdose deaths now
exceed motor vehicle crashes as a cause of
death from unnatural factors. In the 2011
to 2013 interval, the following Kentucky
counties experienced the highest number of
overdose deaths involving pharmaceutical
opioids per 100,000 county residents: Bell,
Clay, Floyd, Johnson, and Knox (Slavova et
al. 2015).
Within the last two months, two federal
agencies have stepped up changes in guidelines for both treatment and marketing of
opioids for chronic pain. In March 2016, the
CDC published guidelines for prescribing
opioids for chronic pain in the United States
(C.D.C. 2016) These guidelines are CDC
recommendations for prescribing opioids for
chronic pain outside of active cancer, palliative, and end-of-life care. The following 12
guideline points are a summary of the entire
CDC recommendations:
1. Non-pharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.
2. Before starting opioid therapy for
chronic pain, clinicians should establish
treatment goals with all patients, including realistic goals for pain and function,
and should consider how therapy will be
discontinued if benefits do not outweigh
the risk.
3. Before starting, and periodically during
opioid therapy, clinicians should discuss
with patients known risks and realistic
benefits of opioid therapy and patient
and clinician responsibilities for managing therapy.
4. When starting opioid therapy for
chronic pain, clinicians should prescribe
immediate-release opioids instead of
extended release, long-acting opioids.
5. When opioids are started, clinicians
should prescribe the lowest effective
dose.
6. Long-term opioid use often begins with
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