Using Caution While Prescribing Opioids for Pain
The Carlat Addiction Treatment Report, Volume 6, Number 3&4, May 2018
Amy Bohnert, PhD
Associate professor of psychiatry at the University of Michigan, Investigator at The Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI
Dr. Bohnert has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: I know you’ve done a lot of research around overdose deaths, both intentional and unintentional, and how this may help psychiatrists more wisely prescribe opioids for pain. Can you start by giving us a little more background on that?
Dr. Bohnert: Sure. I’ll start by talking a little about overdose deaths. The study that we did in the VA with mortality data shows there’s a relationship between the dose of opioids a patient is prescribed and the patient’s likelihood of dying by an unintentional overdose (Bohnert AS et al, JAMA 2011;305(13):1315–1321). What we found is that there’s roughly a linear dose response curve, meaning simply that the greater the dose, the higher the risk of death.
CATR: Can you tell us what you specifically learned about the risk associated with higher doses of opioids?
Dr. Bohnert: Specifically, the risk of death from an overdose with patients prescribed at least 100 mg daily morphine equivalent is about 7 times higher than a patient prescribed less than 20 mg of morphine a day. This paper, as well as additional similar research findings, led to a CDC guideline recommending against prescribing high doses of opioids (see: https://www.cdc.gov/drugoverdose/prescribing/guideline.html).
CATR: So, is there a consensus on what is a safe dose of opioids to manage chronic pain?
Dr. Bohnert: What we found when we did our analysis was that there really was no dose that is completely safe, and there are patients who die of opioid overdoses across the full spectrum of dosages (Bohnert AS et al, Med Care 2016;54(5):435–441). So, there isn’t a point at which you can say, “oh, as long as the patient’s not above 20 morphine-equivalent milligrams, that means there’s no problem.” There’s an overdose risk at every level. But in the interest of trying to encourage physicians to prescribe lower, less risky doses, we determined through the research that less than 50 morphine-equivalent mg per day should be the recommendation put forth in the new CDC guideline. Above 50 mg, the rates of overdose were considerably higher.
CATR: Is there anything else we should know about the CDC guideline?
Dr. Bohnert: Yes. We need to keep in mind that the CDC guideline overall really addresses the question, “How do we approach pain treatment going forward?” What it did not intend to answer was, “What do we do with the cohort of people who were prescribed long-term opioids before the guideline was released?” So, the guideline is more about taking a proactive approach going forward. It also left a lot of unanswered questions, which we’ll need to answer through future research. For example, when is it appropriate to have patients de-intensify or go off opioids? Until we get those answers, it might be a struggle for clinicians dealing with issues of opioid pain management treatment across all clinical settings. The CDC, though, has offered some guidance here (see: https://bit.ly/2oHXK4C).
CATR: Can you tell us more about what you’ve learned while researching deaths associated with intentional vs unintentional opioid overdose?
Dr. Bohnert: We were able to cross-match between medical records data and mortality data, and we specifically looked at the presence of mental health conditions as indicated by diagnostic codes (Bohnert AS et al, Inj Prev 2013;19(5):326–330). What we found was that the risk of intentional overdose (eg, suicide), unintentional overdose, and what we termed “undetermined intent” was associated with essentially every mental health diagnosis group in the study. Not surprisingly, people with a diagnosis of substance use disorder had a stronger association with unintentional overdose deaths and suicide. The undetermined deaths were higher across all the diagnoses, which suggests there are patients who are struggling with a lot of comorbidity—that is, their psychiatric and substance use disorder history makes it more difficult to determine whether the overdose was intentional or unintentional.
CATR: What else can we as psychiatrists and addiction treatment specialists learn from these new CDC guidelines?
Dr. Bohnert: One thing that would be particularly relevant to mental health practitioners is to avoid concurrently prescribing benzodiazepines and opioids. In our VA study, about 50% of those who died from an overdose were on both opioids and benzodiazepines. I think this makes it very important to decide, on a patient-by-patient basis, which of the treatments to prioritize. More research likely needs to be done here, but for now it’s a good idea to proceed with caution when using both medications.
CATR: Do you think overprescribing of opioids is still a problem these days?
Dr. Bohnert: Yes, I think it is still happening to some degree. Some of that is based on consumption data, and we know that—when people get prescribed opioids for acute pain—the common thing to do is to give them more than what they’ll actually need (Bartels K et al, PLoS One 2016;11(1):e0147972). That’s usually to avoid patients calling back into the office to ask for a refill when they’re still experiencing pain. It’s challenging, though, because physicians naturally want the patient to feel like the pain is taken care of, and not being undertreated. But this overprescribing does seem to be more common in an acute pain rather than chronic pain context. With chronic pain prescribing, it’s easier to tell the patient, “I’m going to give you the appropriate amount of pills that you’ll need until I see you in a month, and I won’t be able to give you any extra.”
CATR: I also know that the guidelines speak to screening or diagnosing an opioid use disorder in patients with chronic pain. Can you elaborate on that part?
Dr. Bohnert: There are a couple of things to be thinking about in terms of screening for opioid use problems. If we’re talking about chronic pain patients, the current opioid misuse measure (COMM) is probably my preferred measure for taking a snapshot of someone’s current level of opioid use, and it can pick up on change over time. It includes a brief patient assessment questionnaire (see: https://bit.ly/2IggZbU), and studies have shown the COMM to be a reliable and valid screening tool to help detect aberrant drug-related behavior among chronic pain patients (Butler SF et al, Clin J Pain 2010;26(9):770–776). Another questionnaire assessment tool to consider is the Screener and Opioid Assessment for Patients with Pain (SOAPP). It measures differently than the COMM. The way I would describe the difference is that SOAPP (see: https://www.nhms.org/sites/default/files/Pdfs/SOAPP-5.pdf) is better for predicting at the start of treatment if a patient might be predisposed to developing an opioid use disorder.
CATR: That’s good advice on screening. I’d like to switch gears a little and ask you what you’re seeing in the literature as it relates to non-opioid approaches to treating pain. What are you learning here?
Dr. Bohnert: Just recently, JAMA published a study led by Erin Krebs and colleagues at the Minneapolis VA, where they found that opioid and non-opioid medications were equally effective for treating chronic back, hip, or knee osteoarthritis pain. In fact, that study even showed that those on opioids did a little bit worse. They randomized people on immediate release morphine, oxycodone, or hydrocodone/acetaminophen in the opioid group. For the non-opioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug (Krebs EE et al, JAMA 2018;319(9):872–882). I think that’s a landmark study. Previously, I had not seen any kind of comprehensive head-to-head trial of opioids compared to alternatives that carry a lot less risk. So, we’ll still see how things play out over the next couple of years, but I think that JAMA study has potential to further reinforce the new CDC guideline around deciding when to start opioid pain therapy. Certainly it’s more evidence that fewer patients may benefit from opioid therapy than we once thought.
CATR: Those are definitely interesting findings. What else have you seen in the literature related to alternatives to opioids?
Dr. Bohnert: Another paper that came out in 2016, which was shortly after the CDC guideline, involved a head-to-head comparative effectiveness study of cognitive behavioral therapy (CBT) and mindfulness for chronic pain. The researchers found that both therapies were equally good, and that both were better than receiving nothing (Cherkin DC et al, JAMA 2016;315(12);1240–1249). I think that’s also a really interesting study. It shows that we have a great opportunity to give patients a choice about which of those modalities they think is a better match for them.
CATR: Since it’s related to the topic, what are your thoughts on medication-assisted treatment (MAT) when it comes to opioid use disorders that develop after treating someone with chronic pain?
Dr. Bohnert: In the CDC guideline, there’s a recommendation for using MAT specifically for patients who have developed an opioid use disorder after being on chronic opioid therapy. A consideration, too, is that there’s some evidence of buprenorphine-naloxone (Suboxone) having some analgesic properties that could allow it to treat pain as well as opioid use disorder, but that evidence is somewhat limited. I think in the meantime it’s important that Suboxone not be thought of as the whole of a patient’s pain treatment. This gets to a broader point across all addictions—with someone who has comorbid pain and addiction, it’s really important to be treating both issues. After all, there’s evidence that patients are more likely to relapse if their chronic pain goes untreated.
CATR: So maybe this is where the buprenorphine comes in, but in terms of treating people who have both an opioid use disorder and moderate to severe and chronic pain, did the CDC guideline address that issue?
Dr. Bohnert: Yes. The primary way the CDC guideline addressed it was by providing a guidance around offering Suboxone. So, for patients with an opioid use disorder and chronic pain, it’s definitely appropriate to consider that treatment.
CATR: What are some additional non-opioid treatments you’d recommend for chronic pain?
Dr. Bohnert: There are a lot of non-pharmacologic modalities that can be prioritized as treatment options. For example, there’s yoga and other exercise-based treatments. There’s CBT, mindfulness, acceptance and commitment therapy, and physical therapy. Obviously, insurance coverage for the non-pharmacologic treatments can be an issue, so there is a little bit of swimming against the tide to get access to those for a patient. But even some free programs around pain self-management, such as those for mindfulness or relaxation, are certainly better than nothing. I would say it’s important not only that we help make sure patients’ pain is addressed, but also that we always take their pain seriously.
CATR: Well, this has been a very informative interview. Is there anything you’d like to leave us with on the subject?
Dr. Bohnert: Something that’s really important to me in my work now is to think about how we address access to MAT. Many patients don’t have this. Either they live somewhere where there are very few providers, or their insurance doesn’t give them access to providers who are local, or there are long waiting lists at the local treatment programs. So, I think that’s something that we will need to continue working on as a clinical community.
CATR: Thank you for your time, Dr. Bohnert.