A rational approach to opioid use disorder in primary care

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As a medical student, I understood that dealing with death was part of the practice of medicine. I was prepared to help my patients face the end of life from disease and old age and had steeled myself against the inevitable losses I would see from trauma and infection. However, I had no sense of the incredible burden that opioid addiction and death from unintentional overdose would one day cause.

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To highlight the point, unintentional overdose deaths in 2008 exceeded motor vehicle accidents as the leading cause of accidental death in the United States.1 Since then, the problem has only worsened; by 2014 the US Centers for Disease Control and Prevention reported that 78 Americans were dying each day from unintentional opioid overdose.2

Yet the scourge of deaths from opioid overdose is only the most obvious way that opioid use disorder destroys the lives of patients suffering from addiction, as well as their friends and family. Among many other heartaches, opioid use disorder is associated with severely impaired social function, increased rates of hepatitis C and human immunodeficiency virus (HIV) infection, and serious legal consequences and incarceration.3 Sadly, opioid use disorder has torn apart countless families. Addiction may be a brain disease, but its scope of morbidity extends far beyond the individual with the affliction.


To some extent, physicians are culpable in propagating this epidemic, and not just in their obvious role as opioid suppliers. To be certain, opioid overprescribing is a tremendous problem; in 2014, more than 240 million prescriptions for opioids were issued, enough for every American adult to have his or her own bottle of pills.4

However, there is plenty of blame to go around in the medical system for the problems of overprescribing and inappropriate opioid use. Among other factors, medical schools have historically failed to teach young physicians how to treat pain or prescribe opioids safely,5 and pain specialists are often inaccessible to primary care providers.6 Additionally, pharmaceutical companies have been found guilty of marketing opioids to prescribers in misleading ways,7 and well-intentioned but misguided campaigns such as the “pain as a fifth vital sign” movement may have inadvertently contributed to opioid overprescribing as well.8


Prescribers need to tackle these challenges by educating themselves about when and how to prescribe opioids for chronic pain. Breaking the cycle of overprescribing can be achieved by learning to prescribe opioids rationally, cautiously, and as part of a comprehensive multimodal pain management plan with a commitment to risk assessment and harm reduction. It also means having an exit strategy at the start of opioid therapy. This must include recognizing problematic opioid use when it occurs and having options to offer patients when opioid use disorder becomes the primary problem.

Recognizing the problem

Physicians are notoriously poor at predicting and detecting the presence of aberrant drug use behaviors and opioid use disorder. For example, in a study of patients clinicians thought were not at risk for misuse of medications, 60% had urine drug tests showing either the presence of illicit drugs or no evidence of the prescribed drug.9

The prevalence of problematic opioid use in patients on chronic opioid therapy for pain has been variably reported in the literature, but one systematic review found that misuse rates ranged from 21% to 29% (95% confidence interval 13%–38%) and addiction rates averaged 8% to 12% (3%–17%).10 These numbers are alarming, and prescribers need to know how to screen for and diagnose opioid addiction when they see it.

Importantly, there is a wide spectrum of opioid misuse behaviors, and the wise prescriber will thoughtfully consider each circumstance before assuming a patient has a substance use disorder. For example, one patient may skip doses and “hoard” unused pills for fear that he or she will run out of medication during a pain flare, while another may use opioids for nonmedical reasons such as to get high. Both examples represent aberrant drug use, but in the first case patient education may sufficiently address the problem, while the second may herald a more dangerous and less correctable problem.

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