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How Does the Opioid Epidemic Impact Palliative Medicine Practice?


Introduction and Scope of the Problem

In 2017, the opioid overdose epidemic was declared a public health emergency by the U.S. Department of Health and Human Services. Since 2000, death rates from opioid overdoses have increased by 200%. Life expectancy in the United States began to decrease for the first time since 1959, related to rising overdose deaths and suicide rates. Three distinct waves describe the growth in opioid-related overdose deaths. The first wave (1990–1999) was associated with an increase in medical opioid prescribing, the second wave (2010–2013) resulted from an increasing supply of heroin, and the third wave (2013–present) has caused a significant rise in overdose deaths related to synthetic opioids. While most of the rise in overdose deaths is due to illicit fentanyl (an increase of 90% from 2013 to present), medically prescribed opioids continue to play a role in up to 36% of deaths. The opioid overdose epidemic has had a significant impact on palliative care, including creating barriers to opioid access for patients with serious illness and expanding palliative care clinicians’ scope of practice to include skills related to chronic pain and addiction medicine. These skills include screening for and discussing opioid risk, managing patients with opioid misuse or addiction, identifying and managing diversion, and utilizing a framework that weighs both the benefits and harms of opioids to manage chronic pain. Table 11.1 provides several examples of the impact of the opioid epidemic in the domains of practice, society, and research.

Table 11.1
Changes Caused by The Opioid Epidemic to Palliative Care Practice, Society, Research, and Policy
Practice

  • A global shift in opioid prescribing with less high-dose opioids and less long-term opioid therapy in noncancer pain

  • Implementation of prescription drug monitoring programs

  • Creation of opioid guidelines such as the CDC guidelines that have had benefits (decreased opioid prescribing) and unintended harms (forced opioid tapers and reports of unaddressed pain)

  • Need for universal opioid precautions including screening for substance use disorder, providing naloxone, etc.

  • Increased attention to opioid risk-benefit analysis and awareness

  • Need for primary addiction medicine and chronic pain competencies

  • Difficulty accessing opioids due to pharmacy and regulatory issues such as prior authorizations, pill limits, and decreased opioid supply at pharmacies

  • Challenges in medical decision making when a patient or their surrogate is impaired by a substance use disorder

  • Difficulty accessing addiction treatments for patients with serious illness

  • “Siloing” of palliative care and addiction into separate realms

  • Development of skills in chronic pain and adaptation to opioid challenges with prolonged survival

  • Lack of comprehensive, patient-centered chronic pain programs for palliative care populations that include multimodal therapy

Broad societal challenges for patients, families, and communities

  • Increased stigma around opioid use

  • Efforts to decrease stigma of addiction and opioid use

  • Increased death of young adults and middle-aged population

  • Impact on patients and families such as single-parent households, children raised by grandparents, or caregivers with substance use disorder

  • Family trauma when an individual family loses one or even multiple family members to overdose

  • Medication diversion in hospice

  • Worsening health disparities (in both the treatment of pain and access to addiction treatment)

Need for research and policies

  • Research and policies for screening for opioid misuse risk in the palliative care population

  • Algorithms for opioid misuse and high-risk prescribing

  • Best practices for treatment of a patient with both serious illness and active opioid use disorder

  • Policies for assessing and managing diversion

  • Policies that decrease barriers for opioid use disorder treatment

This chapter will give an overview of the impact of the opioid overdose epidemic on palliative care and describe strategies for assessing opioid benefits and harms in patients with serious illness. Chapter 12 will focus on an approach to managing palliative care patients who have a known or likely substance use disorder.

Summary of Evidence Regarding Treatment Recommendations

Opioid Prescribing and Chronic Pain

Research on the benefits and harms of opioid therapy has greatly expanded in the past decade and primarily focuses on individuals with chronic noncancer pain. Key findings include mixed effectiveness of opioids for pain, high opioid discontinuation rates due to side effects, and risk of opioid use disorder and overdose. These findings prompted changes in recommendations as to how patients with chronic pain and their clinicians decide whether to initiate or continue opioid therapy, and have led to a more opioid-sparing approach. Overall, scrutiny of opioid prescribing practice, opioid prescribing guidelines, and increased awareness of questionable benefit and clear opioid-related harms resulted in a 19% reduction in the annual prescribing rate of opioids from 2006 to 2017. Fig. 11.1 depicts annual opioid prescribing trends, including declining high-dose opioid prescriptions from 2006 to 2017. Data on prescribing trends in palliative care populations are limited, but a small study in patients with cancer reported morphine equivalent doses have decreased by roughly 40% (78 to 48 mg) over the past 6 years.

Fig. 11.1, Annual opioid prescribing trends.

It is important to note that patients with serious illness are routinely excluded from studies that examine the safety and efficacy of opioids. Therefore there is a lack of evidence to guide opioid management decisions and a crucial gap in the literature on both the benefit and harms of opioids in patients with serious illness despite high rates of pain and common opioid use in practice. Given the lack of palliative care–specific guidance, this chapter will include what is known about nonpalliative care populations who suffer from chronic pain. These guidelines can be tailored when appropriate to patients with serious illnesses.

In 2016, the CDC released guidelines to promote safe opioid prescribing in patients with chronic pain, a population for which opioid use is not routinely recommended. The guidelines were intended to assist primary care providers in managing chronic pain by providing recommendations on when to initiate or continue opioids, opioid selection and dose, and assessing the risks and harms of opioid use. The CDC recommendations included prioritization of nonpharmacological therapy, clear established treatment goals for pain and function, periodic evaluation of the risks and benefits of opioid treatment, use of the lowest effective dose, use of immediate-release opioids over long-acting opioids, review of the patient’s history in the prescription drug monitoring program, use of urine tests before starting opioids and subsequent screening at least annually, avoidance of concurrent benzodiazepine prescriptions, and use of evidence-based treatment for patients with opioid use disorder (such as with buprenorphine). The CDC explicitly stated that the recommendations are for chronic pain outside of active cancer, palliative, and end-of-life care. Therefore, although these guidelines can be helpful in understanding opioid harms and opioid treatment recommendations, they do not provide guidance on how to manage long-term opioid use in palliative care practices where opioids can play an integral role. Table 11.2 outlines the current recommendations for opioid therapy in the nonpalliative care population that may inform prescribing practices in patients with prolonged prognoses, with noncancer pain, or at high risk for opioid-related harms.

Table 11.2
Opioid Recommendations in Chronic and Acute Pain
Chronic Pain—Not on Opioids Chronic Pain—on Long-Term Opioids

  • Acute Pain Conditions

  • Long-term opioid therapy not recommended

  • Current risk stratification tools provide no diagnostic value in identifying high- or low-risk patients

  • Possible indications for long-term opioid therapy include scenarios when:

    • 1.

      Alternative lower-risk therapies have not provided sufficient relief or there is a contraindication

      • AND

    • 2.

      Pain is adversely affecting function or quality of life

      • AND

    • 3.

      Personalized assessment of benefits of opioid therapies outweighs harms

      • AND

    • 4.

      Following a discussion on the risks, benefits, and alternatives to opioids.

  • In clinical practice it has been observed that some people experience more opioid benefits than harms, but evidence suggests it is not possible to determine which patients those are at the onset of therapy.

  • Implement an individualized patient-centered treatment plan

  • Abruptly stopping or tapering or discontinuing opioid treatment is almost never indicated

  • There are often times when patient-centered opioid reduction or discontinuation may be indicated. Opioid tapers/reductions are more likely to be successful when dose reductions are made slowly and with psychosocial support. Following successful tapers, patients may experience improvement in pain function, quality of life, and mood.

  • Clinicians should consider opioid agonist therapy such a buprenorphine/naloxone if any of following occurs:

    • 1.

      Evidence of an opioid use disorder

    • 2.

      Difficulty tolerating patient-centered taper due to protracted abstinence syndrome

3.An opioid rotation if a full agonist is no longer providing benefits

  • Opioids are not indicated for minor to moderate pain conditions.

  • Consider opioid therapy for patients with severe pain.

  • Do not withhold opioid analgesics from patients with opioid use disorder with severe acute pain conditions.

  • Opioid dose should be the lowest effective dose for a short duration (such as less than 7 days).

Long-Term Opioid Use for Chronic Pain (>3 Months) Benefit Versus Harm: No long-term studies and only a few of high quality examine the effectiveness of long-term opioids. Studies suggest there may be a modest improvement in pain intensity and function, but clinical significance is unclear. Notably, pain appears to be better controlled by nonsteroidal antiinflammatories and antidepressants than long-term opioids. Evidence of opioid harms occurs in up to 78% of patients (ranging from constipation, dizziness, fatigue, and nausea, to misuse, depression, and opioid use disorder).
Notable Long-Term Opioid-Related Harms : Decreased function/return to work, induced depression related to duration more so than dose, motor vehicle accidents, falls, opioid use disorder, overdose/mortality (increased risks with higher than 100 mg of morphine equivalence, coprescription with benzodiazepines, gabapentinoids, and tramadol)
Note: These recommendations may not apply to some palliative care populations (such as those with cancer pain or a limited prognosis), and the majority are adapted from literature on chronic nonmalignant pain.

The CDC guidelines have had unintended consequences for patients suffering from chronic pain. These include forced opioid tapers, mandated opioid dose reductions, clinicians being unwilling to accept patients on chronic opioids, and institution and insurance policies that limit the use of opioids. Opioid tapering has given rise to anecdotal reports of increased rates of suicide, opioid overdose deaths, and psychiatric destabilization in chronic pain patients. For patients with serious illness, the impact of these policies has also led to issues of opioid access, such as dose limits, lack of insurance coverage, the need for prior authorization, and stigma surrounding the use of opioids.

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