In a previous editorial (Why there is an opioid crisis, February, 2018) I reviewed the origins and public health magnitude of the current national opioid epidemic. We are all familiar with its grim statistics—90 people die each day and over 33,000 die each year in the United States of an opioid overdose, with half of these fatalities due to misuse of prescription opioids.1 Every year, 2 million individuals abuse prescription opioids at a cost of $78.5 billion.2 Women are particularly vulnerable to opioid use disorder (OUD). Compared with men, women are more likely to be treated for chronic pain and appear to develop OUD at lower dosages over shorter durations while experiencing more cravings, a phenomenon known as “telescoping.”3 Between 1999 and 2015, deaths from prescription opioid overdoses increased 471% among women versus 218% among men.3 Thus, ob/gyns, as the primary providers of health care for reproductive age women, are squarely on the front line of the opioid crisis.
It is both simple logic and an established fact that reducing the quantity of opioids prescribed will reduce the occurrence of OUD, the transition to heroin, fentanyl and other illicit opioids, and overdose deaths.4 And yet, as is the case with most physicians, we ob/gyns are “systematically undertrained and under-engaged in addiction treatment efforts.”5 There are also a host of barriers to such training and engagement. For example, to prescribe buprenorphine, an opioid with lower abuse potential and an effective medication-assisted treatment (MAT) for OUD, physicians must obtain a waiver from the Drug Enforcement Administration (DEA) requiring 8 hours of training. Currently only 4% of active physicians have obtained such a waiver. Compounding the problem, insurance companies are often reluctant to cover the higher cost of buprenorphine, forcing physicians to prescribe higher-abuse-potential narcotics for patients with chronic pain.6 So what practical steps can we take to mitigate this crisis?
Strategies to prevent or reduce OUD in non-pregnant women
Prevention of OUD should be the primary focus of gynecological pain relief prescribing strategies. Acute pain associated with gyn procedures may be amenable to nerve blocks and non-opioid analgesics. When opioids are required postoperatively, provide no more than a 3-day supply of an intermediate-release agent at the lowest effective dose.7 Prescriptions for > 7 days should rarely be required.
In the setting of chronic pain (e.g., due to endometriosis), opioid prescriptions should be the last resort and administered only after a careful risk-benefit analysis. In such an evaluation, the physician should be reminded that systematic reviews have failed to demonstrate a benefit to opioid therapy in chronic pain management but do demonstrate an increased risk of OUD, overdose and other harms.8 Thus, alternative treatments such as hormonal therapy, physical therapy, exercise, alternative medicine, behavioral therapy, nonsteroidal anti-inflammatory drugs (NSAIDs) or surgery should be considered depending on the etiology. If, after exhausting all other alternatives, opioids are indicated, the following steps are recommended by the Centers for Disease Control and Prevention (CDC)7:
- Opioid therapy should be considered only if benefits, in terms of pain relief and function, outweigh risks.
- Before initiating opioid treatment, clinicians should establish treatment goals and treatment should only be continued if there is clinically meaningful improvement in pain and function that outweighs risks.
- Before initiating, and periodically while administering opioid treatment, clinicians should review risks and benefits.
- When initiating opioid therapy for chronic pain, clinicians should prescribe intermediate-release opioids and NOT extended-release (long-acting) agents which have greater risk of respiratory arrest.
- Clinicians should prescribe the lowest effective dose and carefully reassess evidence of benefit when doses ≥ 50 morphine milligram equivalents (MME)/day are required; clinicians should avoid doses ≥ 90 MME/day.
- Since long-term opioid use often begins with treatment of acute pain, adhere to the opioid prescribing recommendations made above for acute pain management (lowest dose, intermediate-release formulations, ≤ 3-day duration).
- Reassess benefits and harms within 1 to 4 weeks of starting treatment and every 3 months thereafter while treatment is continued.
- Before starting, and periodically during continuation of opioid therapy, reassess risk factors for possible harm and consider offering naloxone when factors are present that increase risk of overdose (e.g., therapy ≥ 50 MME/day or concomitant benzodiazepine therapy).
- Clinicians should review a patient’s history of controlled substance prescriptions using their state’s prescription drug monitoring program (PDMP) data (http://www.pdmpassist.org/content/state-profiles) to determine whether she is receiving opioid dosages that put her at risk for an overdose. Review PDMP data when starting opioids for chronic pain and every 3 months while on therapy.
- When prescribing opioids for chronic pain obtain urine drug testing before initiating treatment and consider annual testing to assess for prescribed medications as well as other controlled prescriptions and illicit drugs.
- Avoid prescribing concomitant benzodiazepines for patients on opioids because of their synergistic effects promoting respiratory arrest.
- Arrange for MAT with behavioral therapy for patients with OUD.