America in Pain
Chronic pain is a serious issue in the American population, one that will only increase in severity as a significant portion of the population begin to reach the elderly stages of their lives. By the Institute of Medicine’s calculations, chronic pain affects a minimum of 100 million adults in America – a number that surpasses the combined total of those suffering from heart disease, cancer and diabetes.2
Even those Americans whose pain is not chronic still suffer from symptoms that dramatically alter one’s quality of life. Symptoms such as reduced cognitive function, decreased productivity and mental conditions like anxiety and depression impose a large burden on society, with costs to the healthcare system for treating pain estimated at $560 – $635 billion per year.4
In similar fashion to other chronic conditions in the U.S. health system, the treatment of chronic pain varies with only 2% of suffers managed by a pain specialist. Most telling is the estimation that some 50% of all patients diagnosed with chronic pain receive inadequate analgesia (pain relief), despite the sharp increase of prescription opioids for pain management.2
Prescription Opioids
The majority of patients in chronic pain will receive treatment with analgesic medications, particularly oral opioids. An opioid can be defined as any psychoactive chemical analogous to morphine in its effects. Opioids rank among the oldest drugs known to mankind, with therapeutic use of poppy from opium thought to predate recorded history. Opioids react with pain receptors in the central and peripheral nervous system to decrease both the perception of pain and reaction to pain as well increase the patient’s pain tolerance.
The Institute of Medicine describes opioid treatment as an effective option for patients experiencing acute postoperative and procedural pain as well as for patients nearing the end of their life who desire increased pain relief, though even with these indications proper patient screening is vital.
However, oral opioids have been associated with severe side effects such as respiratory depression, nausea and constipation. Even more concerning, the link between opioid use and the development of tolerance to the drug’s psychoactive properties is generally accepted in clinical practice, though poorly understood. Studies have shown that chronic opioid treatment has a connection to the development of tolerance 2, which is particularly alarming considering the euphoria patients often experience with oral opioid use.
A Current Epidemic
The use of opioids to manage chronic pain has skyrocketed, and now accounts for an estimated 20% of all prescriptions in the United States.2 The catalyst is not hard to locate: over the last decade pain specialists and organized medicine elucidated the benefits of treating chronic pain with oral opioids. Consequently in the late 1990s, medical boards at the state level began lifting restrictions on prescribing regulations. The movement continued to gather momentum when the Joint Commission on the Accreditation of Health Care Organizations in 2000 devised novel pain management standards for in-patient and out-patient care.
In retrospect, the force driving the radical acceptance of drugs derived from opium can be attributed to arguments “…based on unsound science and blatant misinformation, and accompanied by the dangerous assumptions that opioids are highly effective and safe, and devoid of adverse events when prescribed by physicians.”4
What was once considered a viable option for combating one of America’s greatest medical issues has morphed into its own enormous problem – the treatment has become a greater threat than the disease.
The numbers regarding opioid deaths are startling. Of deaths related to prescription drug overdoses in 2008 in the U.S., prescription opioids were involved in 73.8%, leading researchers to postulate that a directly proportionate relationship exists between the amounts of opioids prescribed and overdose deaths as measured by state.4, 5 Additionally, some 60% of opioid deaths occur in patients following the prescribing guidelines set forth by state medical boards.4 And opioid deaths are not always the result of abuse: studies have shown that since 1999 more Americans have died from unintentional overdoses of prescription opioids than died in the entirety of the Vietnam War.3
Additionally, nonmedical use of opioids poses its own problems as prescriptions are frequently diverted from patients to family members or friends. As of 2010, 4.8% of the U.S. population older than 12 years had used oral opioids nonmedically.2 The societal costs of the opioid epidemic reach not only patients, but all stakeholders, with nonmedical use of opioids costing insurers an estimated $72.5 billion annually.5
The data sets are telling in their severity. Steps have been taken to change the way opioids release their psychoactive properties, but these new extended release versions include even higher concentrations of opium. Recent data show that the epidemic may be leveling off, leaving the casualty count at approximately 15,000 annually. 4,5
The Topical Analgesic Alternative
With such controversy surrounding the prescribing of oral opioids, it’s natural that physicians would look for alternatives. Consequently, many physicians now look at oral opioids with increased skepticism, with a majority of primary care physicians reporting serious concerns about oral opioid therapy and nearly a third reporting serious adverse events among their patient population treated with opioids.2,3
In the last several years, a new form of opioid therapy has emerged: topical analgesics. In contrast to oral prescriptions, topical analgesics offer a clinically effective path to achieving analgesia in patients suffering from acute or chronic pain while minimizing the risk of adverse events. Adverse events typically occur in oral opioids due to a buildup of high systematic drug concentrations in the patient’s body. Because topical analgesics are applied only at a peripheral site, such as an inflamed knee or shoulder, the likelihood of adverse events is substantially lower. Although some topical opioids do still induce analgesia through both central and peripheral means, the rate of adverse events nonetheless remains significantly lower than traditional oral opioid therapy.1
Topical analgesics are composed of an analgesic element and a combination of drivers that promote absorption through the skin. Absorption variability can exist between respective compounding formulas, but topical analgesic therapy still remains an effective alternative to the high risks associated with oral opioids.1
To date, several studies have validated topical analgesic therapy as more tolerable by patients than oral analgesic therapy. Specifically, topical lidocaine can be recommended for patients with neuropathic pain, and topical NSAIDS have displayed efficacy in alleviating pain radiating from short-term soft tissue injuries and chronic musculoskeletal pain.1 However, additional research should be undertaken to contribute to the growing body of evidence relating to this new form of analgesia therapy.
DC2 is currently researching the efficacy of topical opioids in treating patients with various forms of chronic musculoskeletal pain, with outcomes composed of a combination of patient reported outcomes and physician clinical notes. Study data will be stored and aggregated in a de-identified manner in an Independent Review Board patient registry.
If you’re a prescribing physician interested in contributing to the advancement of analgesia therapy, click the link below to begin the research application process.
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Works Cited
1. Argoff, CE. Topical Analgesics in the Management of Acute and Chronic Pain. Mayo Clinic Proceedings. 2013;88(2):195-205
2. Brennan MJ. Update on Prescription Extended-Release Opioids and Appropriate Patient Selection. Journal of Multidisciplinary Healthcare.2013;6:265-280
3. Franklin GM, Fulton-Kehoe D, Turner JA, Sullivan MD, Wickizer TM. Changes in Opioid Prescribing for Chronic Pain in Washington State. J Am Board Fam Med. 2013;26(4):394-400
4. Manchikanti L, Helm S, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid Epidemic in the United States. Pain Physician.2012;(15):ES9-ES38.
5. Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. Morbidity and Mortality Weekly Report. 2011;60(43):1487-1492. Available at http://www.cdc.gov/mmrw/ Accessed July 17, 2013