The Opioid Challenge.

Most dental practitioners are aware of the increasing controversy in the United States surrounding the prescribing of opioids for postoperative pain. Fortunately, the use of opioids for surgery with general anesthesia and sedation is not a matter of concern in this controversy. It is understandable from a US public health standpoint that opioid prescribing should receive increasing scrutiny. In 2012, there were 259 million US opioid prescriptions, more than enough for 1 bottle for every adult in the United States. Since 1999, there have been more than 140,000 opioid overdose deaths. In 2014 alone, there were more than 28,000 overdose deaths, of which more than 60% were attributable to opioids. There are now more deaths from drug overdose than there are for motor vehicle accidents, the first time this has ever been encountered. The largest increase in overdose deaths is from opioid overdoses, especially from diversion of prescription opioids such as hydrocodone and oxycodone. From 2013 to 2014, there was a doubling of synthetic opioid overdose deaths. In 2013, it is estimated that almost 2 million people abused or were dependent on opioids. Approximately 4% of the US population is currently on long-term opioid therapy for chronic noncancer pain. How did this state of affairs develop? Interestingly, especially for younger doctors who were not practicing at the time and may not be familiar with this recent history, until the late 1990s, opioid use for chronic noncancer pain was mostly prohibited by state medical boards. At that time, case reports indicated that, if patients were well chosen, opioid therapy was effective for chronic pain. Pain advocates, such as the American Pain Society and the American Academy of Pain Medicine, lobbied state medical boards to allow the prescribing of opioids for chronic noncancer pain. The model language that was successfully introduced into most state medical practice acts included, ‘‘No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed. ’’ Long-acting opioids appeared to be preferred for patients with chronic pain based on the reasonable notion that taking opioids on a time-contingent basis, such as twice a day by the clock, was superior to asneeded dosing. This way, patients would not focus on their pain to determine if short-acting pain medication was warranted and thus decrease operant conditioning associated with this behavior. I practiced chronic head and neck pain management, in addition to anesthesiology, for many years. I, too, prescribed long-acting opioids for select patients with chronic pain, such as those with multiple failed temporomandibular joint and other surgeries that developed a significant neuropathic pain component and were unresponsive to other therapies. I typically prescribed methadone, a longacting opioid with NMDA receptor blocking activity, which can exacerbate long QT syndrome, potentially leading to polymorphic ventricular tachycardia. Methadone is frequently singled out as a source of opioid overdose deaths for this very reason. Fortunately, for my patients, they were all screened before therapy with a 12-lead electrocardiogram. In a fascinating case of unintended consequences, we now are coming to a better understanding of the effects of chronic opioid therapy. Although there are clearly patients who benefit from long-term opioid therapy, it is now known that glial activation by opioids exacerbates pain transmission, defeating the purpose of opioids in limiting pain transmission/perception and contributing to opioid tolerance. Other mechanisms have been elucidated that also limit chronic opioid effectiveness. Interestingly, many studies now document that quality-oflife measures are not consistently enhanced for patients on chronic opioid therapy. Functional limitations are frequently not improved. Adverse effects such as drowsiness, severe constipation, and impairment of cognitive function are common—not to mention the risk of overdose, especially for patients taking greater than 80 mg of morphine equivalent opioid per day. Based on all of these factors, the American Academy of Neurology issued a guideline in 2014 stating that the benefits of chronic opioid therapy for some chronic conditions such as headache, fibromyalgia, and chronic low-back pain are likely outweighed by the adverse effects and lack of functional improvement. Most of us remember when, in 2001, the then Joint Commission on Accreditation of Health Care Organizations (JCAHO) mandated that ‘‘Pain is the Fifth Vital Sign. ’’ For the first time, quality of pain control was a focus of accreditation and patient satisfaction surveys. Certainly, quality pain control is a reasonable and worthy goal. But a side effect became that patients now expected that pain was a condition that had to be controlled, maybe completely controlled, both in, and out, of the hospital. Thus, doctors, including dentists, became more accustomed to regular prescribing of opioids for postoperative pain in effort to treat the fifth vital sign.