Opioids 11 controversial the provider must carefully consider the risks and benefits of using this medication class before initiating opioid therapy (Von Korff, Kolodny, Deyo, & Chou, 2011). Medical and nonmedical use of opioids have increased dramatically over time due to several factors. Opioid Prescribing: Past and Present Opioid prescribing accelerated in the 1980s because of arguments made in the scientific literature and policy-driven influences. Low-quality studies published in prominent journals in the 1980s reported a minimal risk of addiction in patients using opioids (Portenoy & Foley, 1986 Porter & Jick, 1980). Another article published in 1990 reiterated the widespread belief that “therapeutic use of opiate analgesics rarely results in addiction” (Max, 1990). Pain was considered “the fifth vital sign,” and relief of pain became one of the fundamental obligations of medical professionals. These studies and the growing pharmaceutical industry led to the liberalization of opioid use for the treatment of pain. Opioid use increased greatly for treating CNCP. Welfare and health care reform in the 1990s also played a role in the overreliance on opioids (Coffin et al., 2016). Managed care organizations recognized that opioids were less expensive than comprehensive pain management clinics and consequently stopped reimbursement for those services (Schatman, 2011). Payers were unwilling to cover nonpharmacological interventions, leaving opioids as one of the few therapeutic options. In the early 2000s, the Joint Commission on Accreditation of Healthcare Organizations published a guide that stated that clinicians’ concerns about opioid-related addiction were inaccurate and exag- gerated. The embrace of opioids by the scientific community, in part due to these highly influential factors, led to changes in physicians’ prescribing prac- tices and a surge in opioid prescriptions (Franklin et al., 2005). This influx of opioid prescriptions is cited as a contributing reason for the opioid epidemic, which has led to opioid dependence and overdose deaths (Meldrum, 2016). In recent years, the medical community has responded with tighter regula- tion of opioids, continuing medical education on the proper use of opioids, and increased availability of addiction treatment. Prescription drug monitor- ing programs (PDMPs) are widely utilized 49 states have operational pro- grams, except for Missouri (U.S. Drug Enforcement Administration, 2016). These changes have led to decreased opioid prescribing and decreased opioid- related morbidity and mortality. It is now more important for clinicians to be able to assess for appropriateness of opioid treatment and potential misuse and to communicate risks and harms than it is to understand the intricacies of opioid management. For more on PDMPs, see chapter 12. The CDC released opioid prescribing guidelines for CNCP in 2016 to pro- vide recommendations to clinicians (Dowell, Haegerich, & Chou, 2016). The
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