Patients with monkeypox seeking relief from painful lesions should only take opioids when alternatives don’t work and after an assessment of their risk for addiction or abuse, public health officials said.
The latest global infectious disease emergency is producing some very painful symptoms, not all of which are visible on an initial examination. The Centers for Disease Control and Prevention guidelines include prescription pain relievers such as opioids among its recommendations for treating pain management associated with monkeypox infection.
As the United States dedicates resources to the monkeypox emergency, the country continues to grapple with the opioid crisis that the Department of Health and Human Services declared an official public health emergency nearly of five years. The risk that the monkeypox epidemic will exacerbate opioid abuse is not as high as the prescriptions to treat chronic pain that largely fueled the crisis of the 1990s. Nevertheless, health care providers should take steps to mitigate the risk of negative outcomes.
“Any time you have to give someone a narcotic, it’s a serious problem,” Georges C. Benjamin, executive director of the American Public Health Association, said in an interview. “Pain management is an art.”
Give the minimum amount
It’s important to only use opioids when other drugs aren’t working, said Robert M. Califf, commissioner of the Food and Drug Administration, in an interview on the agency’s opioid review.
At the same time, the lesions can be “extraordinarily painful”, he acknowledged. They often occur in the oral, genital and anal regions. “There is going to be a need to use opioids. The key is to donate the minimum amount you need for the shortest time possible,” Califf said.
“It’s easy to say, but having been a busy practitioner, I think it’s really important for people like me to recognize how difficult it is when you’re in a busy practice under pressure, you have the next patient to see, assessments are difficult, but I think the general guidelines apply.
The monkeypox epidemic continues to climb in the United States with 20,733 cases as of September 6. However, there are early signs of a potential slowdown in major cities like New York and San Francisco. Meanwhile, drug overdose deaths rose 30% between 2019 and 2020 to nearly 92,000, according to a July report from the Centers for Disease Control and Prevention.
But it is important to treat the symptoms of the disease and offer medical countermeasures, said Boghuma Kabisen Titanji, assistant professor of medicine in the division of infectious diseases at Emory University, during a webinar hosted by the ‘APHA and the National Academy of Medicine.
“Monkeypox lesions have been associated with very painful symptoms for these patients. It is therefore very important that we also take into account the importance of treating these painful lesions and ensuring that the skin lesions heal appropriately in order to minimize scarring once patients have fully recovered,” said Titanji.
Strong push for non-opioids
CDC guidelines recommend a range of strategies for managing monkeypox pain, from sitz baths to over-the-counter pain relievers and “ultimately” to prescription medications such as opioids.
“Pain relief is an essential part of caregiving,” according to the guidelines, signed by CDC Director Rochelle P. Walensky. “Validation of the pain experience can build trust in the healthcare provider and the care plan.”
But the guidelines state that an opioid prescription is only one strategy. They also include a strong recommendation for nondrug strategies and nonopioid pain relievers, said Nora D. Volkow, director of the National Institute on Drug Abuse, part of the National Institutes of Health, in an interview.
“That’s exactly where we should be emphasizing. When you can actually offer an alternative, you should. And only if these alternative treatments don’t relieve the individual’s pain, then you should consider administering an opioid,” Volkow said.
Clinicians should assess each patient’s relative risk for opioid abuse by asking whether the patient has ever had an addictive disorder or had problems with drugs in the past.
What you don’t want to do is prescribe an opioid to someone who gets monkeypox while recovering from heroin addiction, Volkow said. “Because they will relapse.”
The demographic most at risk for drug or substance abuse is younger men, and the latest outbreak of monkeypox also primarily affected men with a median age in their mid-30s.
“We’re going to be dealing with a population of young people, generally young men, who by the nature of their demographics are in principle more at risk of becoming addicted or abusing drugs,” she said. “You must be aware.”
If someone has a history of opioid addiction and nothing else is controlling their pain, it’s important to exercise extra caution and monitor them carefully, Volkow said. But there is no recipe to follow; this intervention must be adapted to the person.
“As much as possible, select opioids that are less likely to produce intense effects associated with rewarding actions and minimize the doses administered,” Volkow said, adding that many times these patients are in a hospital setting, which should lead to a better control of adverse reactions. “But we have to keep an eye on it. Because what we don’t want is for clinicians to take a path of least resistance.
The risk is a little lower
The pain from a monkeypox infection will likely last for several weeks, reducing the risk of abuse compared to prescriptions for chronic pain.
“There’s no question that if we were talking about widespread opioid use, I would be worried about exacerbating the existing opioid epidemic, which still hasn’t gone away,” Benjamin said. “Although the numbers are unacceptable with monkeypox, there is a difference between the number of people you could prescribe opioids for monkeypox, again hopefully a small number” and the number of people who received an opioid prescription that caused the crisis in the 1990s.
At the same time, some abuse resulted from post-operative prescription, Volkow said. “This leads to a certain percentage continuing to take them chronically. So we know that can happen in a relatively shorter administration.
Opioid prescribing fell more than 40% between 2011 and 2020, but there’s still a lot to learn, Califf said.
“It’s a shame that this is so, given the number of prescriptions that have been written over the past few decades,” he said. “We still don’t know exactly where you draw the line between treatment benefits and where you can get away with adequate pain control” with nonsteroidal medication or another alternative, he said.
The NIH is studying some of these prescribing models as part of the HEAL initiative, an agency-wide response to the opioid crisis. Meanwhile, the FDA is reviewing its opioid regulations and on Aug. 30 released a framework aimed at preventing overdose-related deaths nationwide.
—With the help of Céline Castronuovo