Opioids for acute pain: How much is too much?

Scott Weiner, MD

Contributor

Two recent articles have again highlighted how often opioid pain relievers — medications like oxycodone and hydrocodone — are excessively prescribed in the US for acute pain, sometimes for vulnerable populations and sometimes for conditions for which they are probably not even indicated.

The first paper, by authors at Boston Children’s Hospital, evaluated visits to the emergency department by adolescents and young adults (ages 13 to 22) over an 11-year period from a nationwide sample. About 15% of patients — roughly one in six — were prescribed an opioid, with high rates seen for ankle sprains, hand fractures, collarbone fractures, and particularly dental issues, for which an incredibly high 60% of patients in this age group received an opioid.

Speaking of dental issues, the second paper compared opioid prescribing by dentists in the US and England. In this study, the researchers looked at opioid prescriptions in 2016, and the numbers are shocking. In the US, 22% of prescriptions written by dentists were for opioids, compared with just 0.6% for British dentists, and US dentists prescribed about 35 opioids per 1,000 population, compared to just 0.5 opioid prescriptions per 1,000 population in England. Additionally, the opioid prescribed in England was a relatively weak codeine-like drug, whereas in the US the majority of prescriptions were for hydrocodone, a stronger opioid with greater abuse potential.

When does an opioid prescription make sense?

It is simply impossible that pain experienced by people in the US is that staggeringly different than in the UK. So why the discrepancy? While it is possible that pain is being undertreated in the UK and more adequately treated in the US, I don’t believe that to be the case. The difference is that, in the US, prescribers were reassured for years that opioids were a safe and effective way to treat pain. And yes, they are effective, but as evidenced by the vast increase in opioid-related overdose deaths seen in the country over the past decade, they are not safe.

On the other hand, medications like acetaminophen and ibuprofen — those over-the-counter pain medicines that you can get at any supermarket — actually work amazingly well for acute pain. As an example, a large survey study of over 2,000 patients who underwent a range of dental procedures discovered that the vast majority experienced adequate pain relief with over-the-counter or non-opioid prescribed pain medications. And similar studies are abundant. Another study looked at patients treated for low back pain in the emergency department and found no difference in pain after five days, whether the patient was treated with an anti-inflammatory medicine (naproxen) or if an opioid was added. It just didn’t make a difference, so why take the risk?

Yet another study evaluated variation within the US for treatment of ankle sprains. Over 30,000 patients were studied. On average, about a quarter of patients received an opioid prescription, but the state-level differences were astounding, ranging from under 3% in North Dakota to 40% in Arkansas! All for a condition that, in general, should get better with ice, elevation, and a brace.

Of course, there are times when the over-the-counter medications are not going to be sufficient to treat acute pain. In those situations, the goal should be to take the non-prescription medications first, and then add an opioid only when the pain is unbearable. Typically, this period of severe pain is in the first three days after a surgery or trauma. For example, colleagues in my department evaluated opioid consumption in the days after suffering an acute fracture. Most patients needed only about six pills of oxycodone.

The same trend is seen after surgery. A large study of six other studies found that between two-thirds and 90% of post-operative patients reported unused opioids after their surgery, and as many as 71% of the tablets went unused. We therefore subscribe to the recommendations of the Opioid Prescribing Engagement Network (OPEN) program in Michigan, which recommends relatively small opioid prescriptions after surgery, such as 10 pills after having your appendix removed or hernia repaired, and just five for procedures like a breast biopsy. Patients do fine, even with these smaller numbers of pills, and are at less risk of developing long-term opioid use.

What to be aware of for teenagers and young adults who get an opioid prescription

My general recommendation for opioid-naïve patients, regardless of age, is the following: if you have a simple problem, like a sprain or a dental procedure, or even back pain, do whatever you can to avoid an opioid. Ask your doctor about which over-the-counter pain treatments you can safely take and maximize those. For more severe pain, such as from fractures or after surgery, use the minimum number of opioids needed to tolerate the pain, then back off once the pain is bearable and continue with the non-prescription treatments.

For adolescents and young adults, extra caution is needed. The adolescent brain is developmentally predisposed to developing addiction, and therefore at high risk. Although opioid misuse among teens is decreasing, it still is a major problem. Among high school seniors, past-year misuse of pain medication was 3.4% in 2018, and about a third of high school seniors thought that these drugs are easily accessible. It is therefore paramount to protect adolescents from these medications. If prescribed, they should ideally be stored securely and dispensed by a parent or guardian following the appropriately prescribed schedule. Education about the medicine, and the dangers of being dependent on the medication, is essential. This is also a great time for parents to talk to their children about drug use in general.

What to do with leftover pills

When the acute pain from those first few days is gone, if there are leftover opioid pills, discard them safely. I cannot reiterate this enough. About two-thirds of adolescents who misused opioids got them from friends or family for free. There are lots of places to safely discard pills. In fact, the Drug Enforcement Administration offers a website that lists the closest bin locations. If one of those is not accessible, mix the medication with coffee grounds or dirt, seal it in a plastic bag, and dispose of it in the trash. Just be sure not to flush it down the toilet, as opioids and other drugs can contaminate the water supply.

Comments:

  1. Kaylyn

    I have wondered how a pain medication called an opioid was ever considered by any doctor to be something that was safe to prescribe so freely in the first place. And I don’t mean undertreating. Yes, treat the heck out of severe pain. I’m referring to the days when a month’s supply of 4 or 6 pills a day with 3 refills was considered normal procedure,then time for your appointment for the next few months’ supply. That’s how I remember the whole thing starting Seems like the name opioid says it all & I find it outrageous to believe that the prescribers didn’t know what was going on. I mean,were the sales pitches just that good? That persons with medical degrees were being scammed by smooth talking sales reps?? I have to say, I don’t think so.And as far as taking otc pain relievers for fractures until the pain becomes unbearable then take the prescription opioid is backwards. Isn’t it better and more effective to get ahead of the pain before it’s unbearable? In my case, if the pain had already gotten to a certain point, it was too late to take the rx because nothing less than a shot of morphine or something strong would have helped. A pill would have done nothing at that point, just wasted medication. I’m not a proponent of rx meds in general but if they’re needed, instead of generalizing everyone based on a pill count, treat the patient’s needs. A Dr should know when their patient is over that curve of severity & don’t need the stronger meds any longer. Why it was let to ever go any other way is something that happened, it shouldn’t have happened, but nonetheless here we are. I realize it was probably mostly not in the acute pain scenario but it shouldn’t have happened in any scenario. The people who live with chronic intractable pain, though, are losing their lives because of their pain, so trade the overdose victims who will od anyway & let the people who have been able to have some semblance of a life suffer, literally, to death. If they can be monitored now, they could have been all along so yeah, those prescriptions were written I believe with full knowledge of addiction potential. It seems like a fantasy that prescribers didn’t know, maybe they just ignored since it was ok to do it & keep those patients coming back. Most Drs ended up abandoning their now dependant patients saying they didn’t know. Hiding behind and blaming the pharma. Yes pharma played their role, but come on, Drs saying they didn’t know is a fallacy.

  2. M jones

    Obviously, a physician that never had a toothache. Regarding British dental care, no where near the same treatment as US. Look at the teeth of the the royal elders, sad, all that $ and horrific looking dental care. Furthermore, what is the “weak” codeine like drug prescribed in Britain? Tylenol 3? Codeine is an opiate. Try some regular acetaminophen with an abscessed tooth, good luck functioning thru the day and then trying to sleep. Especially in the summer heat. Not everyone lives in air conditioned comfort. Most dental infections resolve in 72 hours with appropriate antibiotic treatment, opioid pain relief, properly prescribed, thru that time period, is good safe treatment. Give me US dental care any day, over anywhere else in the world. Sorry doc, you’re all wet on this one.

  3. Stuart Percell

    The current overdose crisis is rooted in the intersection of long-term psychosocial and cultural trends combined with the lucrative opportunities unintentionally created by drug prohibition.

    Misdirected government policymakers really need to abandon the “one-size-fits-all” intrusions into the once sacred physician–patient relationship.

    Defenders of the false narrative continue to falsely believe that the population of nonmedical users consists primarily of patients who were inappropriately prescribed opioids for painful conditions. Based on that false premise, they reason that reducing opioid prescribing in conjunction with better drug interdiction and expansion of drug treatment should gradually eliminate the problem. Unfortunately, the data does not support that expectation.

    Government policymakers should consider providing more harm reduction measures such as expanded access to medication-assisted treatments, needle exchanges, and possibly supervised injection facilities. Naloxone should be rescheduled by the FDA in order to make it more easily available (possibly as an over-the-counter drug).

    Health care and pain management are very individualized undertakings. Current government policies aimed at reducing opioid overdoses are entirely misdirected and completely ignore that fact.

    Opioid prescribing is at its lowest volume in the previous 15-years while overdose deaths “involving opioids” continue to escalate annually. Consequently, the current overdose crisis is very likely one of the many unintended consequences of government’s misdirected prescription drug prohibition.

    Drug prohibition has provided substantial economic incentives for illicit narcotic manufacturers to re-supply banned substances which are in very high demand.

    Prescription drugs are not now, nor have they ever been the primary driving component of the deceptively named “opioid crisis.” We are actually experiencing an “illicit heroin and fentanyl crisis.”

    Reducing prescriptions has not (and will not) reduce “opioid-related” deaths. It’s merely driving up the death toll by pushing nonmedical users toward deadlier “street” drugs. A more rational approach, based on an accurate narrative, would emphasize measures aimed at reducing the harms associated with consumption of street opioids.

    Chronic pain patients deserve/need more individualized medical care and less heavy-handed government policies.

    • Billy Brockway

      I am a croninck pain patient and taking Roxicodone for about 15+ years I’ve never once had a problem with taking my meds that is helped ,now I’m being pulled in as a attic and it’s wrong. So know I suffer through my day of pain I’ve had tried CBD OIL. Don’t work.

  4. Richard A Lawhern PhD

    Dr Weiner, you state “in the US, prescribers were reassured for years that opioids were a safe and effective way to treat pain. And yes, they are effective, but as evidenced by the vast increase in opioid-related overdose deaths seen in the country over the past decade, they are not safe.”

    I must suggest, sir, that you are repeating a popular mythology. Overdose related deaths in the US are driven almost entirely by illegal drugs, and they always have been. When published data of the CDC are plotted for State by State rates of opioid mortality from all sources (legal, diverted, or illegal) versus rates of physician prescribing in the same States, we find no cause and effect relationship at all. Indeed, inconveniently for your premise, in 8 of the 9 States where prescribing rates are highest, mortality is lower than the US National average. And in 8 of the 10 States where prescribing rates are lowest, mortality is higher than the US National average.

    The demographics are also contradictory: People over age 55 are prescribed opioid pain relievers three times more often than youth under age 25. But mortality in youth has soared over the last 20 years to levels now six times higher than in seniors.

    We do have an opioid problem in the US. But it isn’t sourced in medical exposure to opioid pain relievers, and it never was. For further discussion of this data, see “Stop Persecuting Doctors for Legitimately Prescribing Opioids to Chronic Pain Patients” in the June 28 edition of STAT News.

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