Chapter 25: Opioids

INTRODUCTION

Opioid analgesics play a central role in pain management; hydrocodone-acetaminophen is the most commonly prescribed medication the United States. At the same time, widespread use of opioid analgesics to treat chronic pain in the 1990s and 2000s contributed to a rapid rise in opioid-related deaths and patients diagnosed with opioid use disorder. In 2016 more than 42,000 deaths in the United States were associated with prescription opioids, including 1 in 5 deaths among adults between 25 and 34 years old. Encouraging behavioral change related to pain and opioids can be especially challenging; both clinicians and patients report that conversations about opioids, especially opioids prescribed for chronic pain, are frequently frustrating and unproductive.

Because of the rise in opioid-related deaths, opioid analgesics are currently the focus of intense clinical and health services research. Laws, policies, and regulations related to opioid prescribing are also rapidly changing. In most cases these changes involve increasing regulations and restrictions around opioid prescribing.

This chapter provides practical strategies clinicians can use to encourage behavior change related to managing opioids, with a focus on opioid prescribing for chronic pain. Two overarching principles should be kept in mind when managing prescription opioids:

1. Decisions to prescribe opioids should be based on the overall balance of opioid-related risks and benefits for individual patients. Assessing risks and benefits requires attention to both patients’ perspectives and objective evaluation of patients’ functional status and opioid-related risks, particularly overdose and substance use disorder.

2. Effective communication is critical for managing prescription opioids. Effective communication requires taking the patient’s pain seriously, managing the unpleasant emotions that often arise (for both patients and clinicians) during discussions about opioids, and navigating disagreements, all while maintaining a therapeutic relationship.

Skillful opioid prescribing and effective communication require clinical knowledge of both pain management and management of substance use disorders. These important topics are discussed in more detail in Chapters 38 and 24, respectively. This chapter focuses on challenges that are relatively unique to prescription opioids.

HISTORICAL PERSPECTIVE ON OPIOIDS

The attitude of organized medicine and society towards opioid analgesics has shifted over time, sometimes emphasizing opioids’ ability to reduce pain and relieve suffering, and other times emphasizing opioids’ addictive, destructive potential (Table 25-1). Opioids are chemical derivatives of opium, which is harvested from the seed pods of the opium poppy, Papaver somniferum. Opium has been cultivated and used for thousands of years for both therapeutic and recreational purposes. Processed opium is either smoked or swallowed, usually in the form of a liquid solution. Laudanum, a tincture of opium mixed with alcohol, was popularized by Thomas Sydenham in the 1660s. Morphine is a naturally-occurring component of opium that was isolated in the early nineteenth century and was commercially available in Europe and the United States by the 1820s. Morphine became extremely popular in large part due to the ...