Opioid Treatment for Monkeypox Means Balancing US Health Crises

Monkeypox patients seeking relief from painful lesions should only take opioids when alternatives don’t work and after an evaluation for their risk of addiction or misuse, public health leaders said.

The latest global infectious disease emergency produces highly painful symptoms, not all of which are visible on an initial exam. The Centers for Disease Control and Prevention guidelines include prescription painkillers such as opioids among its recommendations for treating pain management associated with a monkeypox infection.

As the US pours resources into the monkeypox emergency, the nation continues to grapple with the opioid crisis which the Department of Health and Human Services declared an official public health emergency nearly five years ago. The risk of the monkeypox outbreak exacerbating misuse of opioids isn’t as high compared to prescriptions to treat chronic pain that in large part fueled the crisis in the 1990s. Nevertheless, health-care providers should take steps to mitigate chances of any negative outcomes.

“Anytime you have to give someone a narcotic, it’s a serious issue,” Georges C. Benjamin, executive director of the American Public Health Association, said in an interview. “Managing pain is an art.”

Give the Minimum Amount

It’s important to use opioids only when other medicines don’t work, Robert M. Califf, commissioner of the Food and Drug Administration, said in an interview about 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’s going to be the need to use opioids. The key there is to give the minimum amount you need to give for the shortest time possible,” Califf said.

“This is easy to say but having been a busy practitioner, I think it’s really important for people like me to acknowledge how hard it is when you’re in a busy practice under pressure, you got the next patient to see, assessments are difficult. But I think the general guidelines are applicable.”

The monkeypox outbreak continues to climb in the US with 20,733 cases as of Sept. 6. However, there are early signs of a potential slowdown in major cities such as New York and San Francisco. Meanwhile, drug overdose deaths increased from 2019 to 2020 by 30% to nearly 92,000, according to a July report from the Centers for Disease Control and Prevention.

Vaccines, namely Bavarian Nordic A/S’s Jynneos, are available both for pre and post-exposure prophylactics. Siga Technologies Inc.’s smallpox antiviral Tpoxx can also be used to treat monkeypox under an expanded access protocol.

But it’s important to treat the symptoms of the disease as well as offering medical countermeasures, Boghuma Kabisen Titanji, assistant professor of medicine Emory University’s infectious diseases division, said 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. So it’s very important that we also factor in the importance of treating these painful lesions and ensuring that the skin lesions heal appropriately so that we minimize scarring once the patients have fully recovered,” Titanji said.

Strong Push for Non-Opioids

The CDC guidelines recommend a range of strategies to manage monkeypox pain, from sitz baths to over-the-counter pain relievers and “ultimately” prescription drugs such as opioids.

“Relief of pain 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 care provider and care plan.”

But the guidelines make clear that a prescription for opioids is just one of the strategies. They also include a strong recommendation for non-medication strategies and non-opioid painkillers, Nora D. Volkow, director of the National Institute on Drug Abuse, part of the National Institutes of Health, said in an interview.

“That’s exactly where we should be emphasizing going. When you actually can provide an alternative, you should do that. And only if these alternative treatments do not relieve the pain of the individual, then you should consider administering an opioid,” Volkow said.

Clinicians must evaluate each patient’s relative risk for misuse of opioids by asking if the patient has ever had an addiction disorder or had problems with drugs in the past.

What you don’t want to do is prescribe an opioid for someone who contracts monkeypox while they’re in recovery from a heroin addiction, Volkow said. “Because they will relapse.”

The demographic that’s at highest risk of drug misuse or addiction is younger men, and the latest monkeypox outbreak has primarily also been in men with a median age in their mid-30s.

“We’re going to be dealing with a population of young people, usually young males, that by the nature of their demographics, in principle, are at higher risk of becoming addicted or misusing drugs,” she said. “You have to be aware of that.”

If someone has a history of opioid addiction and nothing else controls their pain, then it’s important to exercise extraordinary caution and monitor them carefully, Volkow said. But there’s no one recipe to follow; that intervention must be tailored to the individual.

“As much as possible, select opioids that are less likely to produce intense effects associated with rewarding actions and minimize the doses that are given,” Volkow said, adding that many times these patients are in a hospital setting which should lead to better control of untoward reactions. “But we have to keep an eye on it. Because what we don’t want is for clinicians to go with a path of least resistance.”

Risk Is Somewhat Lower

The pain caused by a monkeypox infection will likely last several weeks, which lowers the risk for misuse compared to prescriptions to treat 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. “While the numbers are unacceptable with monkeypox, there’s a difference between the number of people who you might prescribe opioids for monkeypox, again, hopefully a small number” and the number of people who received an opioid prescription that drove the crisis in the 1990s.

At the same time, some misuse was a result of a post-surgery prescription, Volkow said. “That leads a certain percentage to continue to take them chronically. So we know that can happen within a relatively shorter administration.”

Opioid prescribing has dropped more than 40% between 2011 and 2020, but there’s still a lot to learn, Califf said.

“It’s a shame it’s this way, given the number of prescriptions that have been written over the last decades,” he said. “We still don’t know exactly where you draw the line on where the treatment is beneficial and where you can get away with adequate pain control” with a non-steroidal medicine or some other alternative, he said.

The NIH is studying some of these prescribing patterns as part of the HEAL Initiative, an agency-wide response to the opioid crisis. Meanwhile, the FDA is reviewing its regulations on opioids and released a framework Aug. 30 aimed at preventing overdose-related deaths nationwide.

—With assistance from Celine Castronuovo