Patrice A. Harris
Jai N. Patel
Prescription opioid volumes declined by 29% from their peak in 2011, according to a report on medicine use in the United States by IQVIA.
Prescription opioid volumes peaked in 2011 at the level of 240 billion morphine milligram equivalents (MME). By the end of 2017, levels had decreased to 171 billion MME.
This decrease “reflects the fact that physicians and other health care professionals are increasingly judicious when prescribing opioids,” Patrice A. Harris, MD, MA, chair of the AMA Opioid Take Force, said in a statement. “It is notable that every state has experienced a decrease, but this is tempered by the fact that deaths related to heroin and illicit fentanyl are increasing at a staggering rate, and deaths related to prescription opioids also continue to rise.”
New starts of opioid therapy — reported at 3.4 million per month in 2015 — fell to 2.9 million per month at the end of 2017.
From 2015 to 2017, treatment initiations of medication-assisted therapies for opioid use dependence nearly doubled from 44,000 per month to 82,000 per month. This increase likely is an effect of increased funding and support for programs that address addiction, according to the report.
The report also showed opioid prescriptions declined by 10.2% per month in 2017. Also, high doses of prescription opioids — more than 90 MME — declined by 33.1% since January 2016 and fell by 16.1% during 2017.
“These statistics again prove that simply decreasing prescription opioid supplies will not end the epidemic,” Harris said in the statement. “We need well-designed initiatives that bring together public and private insurers, policymakers, public health infrastructure and communities with the shared goal to improve access and coverage for comprehensive pain management and treatment for substance use disorders.”
Opioids play a large role in pain management for patients with cancer, according to Jai N. Patel, PharmD, BCOP, chief of pharmacology research at Levine Cancer Institute at Carolinas HealthCare System and a HemOnc Today Editorial Board Member.
“It is important that providers are more vigilant about prescribing opioids, and the guidelines set forth by the CDC help ensure limited opioid quantities for patients with noncancer-related pain,” Patel told HemOnc Today. “However, oncologists must also realize that opioids are the mainstay treatment for cancer-related pain and should not withhold therapy [for] patients who need them and do not have any contraindications. Better methods of screening patients at high risk for drug abuse are needed to avoid the need for medication-assisted treatment of opioid use disorder.”
Screening methods such as Current Opioids Misuse Measure — or COMM — and Screener and Opioid Assessment for Patients with Pain, known as SOAPP, can help identify patients who are at high risk for addiction. However, these tests are not always reliable, Patel said.
“Research is needed to identify additional clinical risk factors and biological factors, like genetics, that can predispose someone to drug addiction,” Patel said. “Combining significant predictors can improve current screening methods.”
Risk-mitigation strategies for high-risk patients — such as use of nonopioid medications or nonpharmacological methods like acupuncture, massage and exercise — may help reduce the burden of opioid use disorder, Patel added.
“Referral to palliative medicine, monitoring of prescription drug databases, urine toxicology screens and monitoring for aberrant drug behaviors are all effective tools to mitigate the risk of opioid use disorders [among patients with cancer,” he said.
Patients with cancer are less likely to have risk factors for opioid abuse than those who have chronic pain caused by something other than malignancy, Paul A. Glare, MBBS, FRACP, FACP, director of Pain Management Research Institute at The University of Sydney in Australia, told HemOnc Today.
“Cancer survivors, including people on long-term maintenance cancer treatment, are in a somewhat different situation,” Glare said. “Opioids don’t seem to work as well after 6 months of continuous use so, if survivors have chronic pain, then oncologists should start thinking about weaning the opioids and using other approaches if they have chronic pain, with referral to a pain clinic for more complex cases.”
“[Beyond] pain caused by cancer treatment — such as postsurgical pain or chemotherapy-induced peripheral neuropathy — older cancer survivors have painful comorbidities that can be aggravated by the deconditioning associated with having cancer and cancer treatment,” Glare said. “These should be managed appropriately, not with opioids.”