Chronic pain is a debilitating disorder affecting approximately 100million people, or almost 30% of the adult population of the United States.1 Among patients with chronic pain, about half report its occurrence to be daily and severe. Chronic pain costs about $630 billion annually and is the leading primary complaint by patients to healthcare providers and the chief reason for lost productivity. The annual cost of pain is greater than that of coronary heart disease ($309 billion), cancer ($243 billion), and diabetes ($188 billion).2 In the United States, the most frequently prescribed treatment for pain is opioids, which may lead to opioid use disorder. Opioid use disorder is a serious chronic relapsing condition that has been estimated to affect about 2million Americans and costs about $80 billion annually. In the United States today, opioid use disorder is a leading cause of accidental death and a major contributor to the heroin epidemic.3
The United States represents about 4% of the world’s population but prescribes 80% of painkillers and accounts for 27% of deaths due to drug overdose. During the 10years of the Vietnam War, over 58,000 US lives were lost. In contrast, last year alone, over 72,000 American deaths were related to opioid use disorder. Furthermore, in the United States, overall life expectancy had been increasing for almost 70years until last year, due mainly to declines in deaths from cardiovascular disease. However, US life expectancy is no longer increasing, due at least in part to the alarming rise in deaths from prescription drug overdose, particularly in whites of lower socioeconomic status. Among the estimated deaths from prescription drug overdose last year, the major contributors are prescription opioids and heroin. Opioid use disorder also contributes to high morbidity due to deleterious interactions with other medications, and misuse, diversion, or switching to heroin when prescriptions can no longer be obtained. In the United States today, more than 2million adults and children are estimated to suffer from opioid use disorder.3
There is currently much debate regarding the causes of and solutions to opioid use disorder. The major unresolved issues involve diagnosis, treatment, and prevention. An accurate diagnosis is critical to identify the prevalence of opioid use disorder which, in turn, would facilitate efforts at treatment and prevention. The gold standard is the use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria by psychiatrists. This strategy, however, is not feasible due to the large number of primary healthcare providers who prescribe opioids. At present, one aspect of our research focuses on evaluating the use of electronic health records, medication use agreements, and other proxies to code for DSM-5 criteria indicative of opioid use disorder. Our efforts include assessing the prevalence of opioid use disorder in a large chronic pain population taking opioids for moderate to severe musculoskeletal pain. In this population, there is a marked underdiagnosis of opioid use disorder based on International Classification of Diseases-10 codes. Based on medication use agreement data, the prevalence of moderate to severe opioid use disorder is approximately 1 in 5 but may be even higher by coding for DSM-5 criteria derived from existing information in electronic health records. In a smaller study of this same population, use of psychiatric interviews yielded a prevalence rate of 13% for moderate to severe opioid use disorder.
With regard to treatment, healthcare providers must first acknowledge their role in contributing to opioid use disorder and seek additional training to recognize this disorder as a chronic disease and to eliminate the stigma sometimes conveyed to patients, which can be a barrier to treatment. Initial efforts to address opioid use disorder have been primarily focused on reducing nonmedical use of opioid pain relievers. However, the marked increases in the number of annual opioid prescriptions written in the United States over the past several years, make it even more important and timely to accumulate the reliable evidence that is necessary to inform clinical decisions for individual patients and policy decisions for the health of the general public.
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-Janet Robishaw, PhD, Jennifer Caceres, MD, Charles H. Hennekens, MD, DrPH
This article originally appeared in the April 2019 issue of The American Journal of Medicine.
