Download Opioid Abuse and Current Prescribing Guidelines

Opioid Update
Alice Messer, FNP-BC, DNP(c)
OPIOIDS
• Opioids have been regarded for a
millennia as the most effective drugs for
the treatment of pain.
• Their use in the management of acute
severe pain and chronic pain related illness
is considered the standard of care in most
of the world. (NIH Public Access)
• The long term use of opioids in chronic
non-malignant pain is controversial.
The past
• Diacetylmorphine (heroin) was first promoted
by Bayer as less addictive than morphine.
• In the 20th century research advances and
major changes in the way of opioids were
used occurred.
• Specifically during the 1990’s the use of
opioids for chronic pain began to increase
and pain was labeled the 5th vital sign by Joint
Commission on the Accreditation of
Healthcare Organizations.
THE PAST
• Pharmaceutical companies provided grant
money to establish guidelines for the
treatment of pain.
• Physicians, nurses, hospitals etc. were
educated through mandatory in-services and
CEU’s in treatment of pain.
• Physicians were sued for the under treatment
of pain.
• The thought at that time was everyone has
the right to the treatment of pain with
narcotics.
AFTERMATH
• The National Survey on Drug Use and Health
reported that the number of first time
abusers of prescription opioids increased
from 628,000 in 1990 to 2.4 MILLION by
2004.
• Admissions for the treatment of opioid abuse
increased 186% between 1997 and 2002.
• The office of National Drug Control Policy
reports prescription drug abuse as the fastest
growing drug problem in the nation. 2nd only
to marijuana
AFTERMATH
• According to the Mississippi State
Department of Health 90% of accidental
overdose deaths in Mississippi were
caused by prescription drugs.
• Some sources estimate prescription
painkillers now outnumber those of heroin
and cocaine COMBINED.
• In 2009 drug poisoning deaths surpassed
traffic related crashes as the leading cause
of injury death in the United States.
AFTERMATH
• In 2015 Prescription pain killers were more
widely used than tobacco
• 35% Americans given pain killers in 2015
• In 2014, 19,000 Americans died due to
opioid abuse or misuse
• In 2014 more people died from opioids
than those from homicide (15,809)
Opioid epidemic
• https://www.youtube.com/watch?v=oHE2--uazXI
• Nearly 1 in 5 teens report abusing
prescription medications.
• 2 in 5 teens believe prescription
medications are safer to try than illicit
drugs.
• Most believe prescription pills are not
addictive.
TEENS
• Teens report obtaining prescription pain
killers from friends, family members or
from the cabinets of friends or family
members
• LOCK IT UP
WHAT NOW?
• Just don’t prescribe pain killers?
• What if it’s you or your family member?
• Pain has consequences: suicide, divorce,
disability, self medicating with alcohol or
illegal drugs
• Pain is the most common medical
complaint and can be difficult to
effectively diagnose, treat, and manage,
especially in patients suffering from
chronic pain.
ETHICAL CONSIDERATIONS
What if there is no cure
• Back pain unrelieved or worsened by
surgery, joint deformities or trauma,
rheumatoid, complex regional pain
syndrome, peripheral neuropathy,
ankylosing spondylitis, cancer
• Human suffering
• Do we have a right to expect treatment to
relieve our suffering?
•
ETHICAL CONSIDERATIONS
Ongoing pain has devastating consequences on
quality of life and slowly deteriorates a person’s
physical, emotional and spiritual well being
Pain affects both body and mind directly by
activation of stress related mediators and
indirectly by causing inactivity, insomnia,
anxiety, depression.
Uncontrolled chronic pain exacerbates preexisting conditions such as diabetes, heart
disease and psychiatric conditions
Chronic pain increases risk of suicide
ETHICAL CONSIDERATIONS
• The use of opioid analgesics is controversial.
They can be diverted and abused with
potential life threatening consequences.
• Opioids are one of the most prescribed drugs
in the united states
• We prescribe more hydrocodone than the
world according to the National Institute of
Drug Abuse
• Pain is subjective. A clinician cannot prove or
disprove patients pain
RISK VS BENEFIT
• The goal of pain management is to
decrease pain and increase function
• Risk/Benefit
• All treatment has a risk benefit ratio
• Even treatments other than opioids have
potential devastating consequences
• NSAID-GI bleed, kidney failure
RISK VS BENEFITS
• Muscle relaxers- liver failure, altered mental
status
• Physical therapy – fractures, joint injury, muscle
injury
• Surgery – stroke, heart attack, paralysis, death
• Injections – infection, bleeding, pneumothorax,
tissue trauma
• Steroids – osteoporosis, avascular necrosis,
uncontrolled glucose in diabetes, hypertension
CDC Guidelines
• Non pharmacologic therapy and non
opioid therapy are preferred for chronic
pain. Providers should only consider
adding opioid therapy if expected benefits
for both pain and function are anticipated
to outweigh risks to patients (Category A,
evidence type 3).
CDC GUIDELINES
• Before starting opioid therapy for chronic pain,
providers should establish treatment goals with
all patients, including realistic goals for pain and
function. Providers should not initiate opioid
therapy without consideration of how therapy
will be discontinued if unsuccessful. Providers
should continue opioid therapy only if there is
clinically meaningful improvement in pain and
function that outweighs risk to patient safety.
(Category A, evidence type 4)
CDC GUIDELINES
• Before starting and periodically during
opioid therapy, providers should discuss
with patients known risks and realistic
benefits of opioid therapy and patient and
provider responsibilities for managing
therapy (Category A, evidence type 3)
CDC GUIDELINES
• When starting opioid therapy for chronic
pain, providers should prescribe
immediate-release opioids instead of
extended-release/long acting opioids
(Category A, evidence type 4)
CDC GUIDELINES
• When opioids are started providers should
prescribe the lowest effective dosage. Providers
should use caution when prescribing opioids at
any dosage should implement additional
precautions when increasing dosage to greater
than or equal to 50 morphine milligram
equivalent (MME)/day, and should generally
avoid increasing dosage to greater than 90
MME/day (Category A, evidence 3).
CDC GUIDELINES
• Long-term opioid use often begins with
treatment of acute pain. When opioids are used
for acute pain, providers should prescribe the
lowest effective dose of immediate-release
opioids and should prescribe no greater quantity
than needed for the expected duration of pain
severe enough to require opioids. Three or
fewer days usually will be sufficient for most non
traumatic pain not related to major surgery
(Category A, evidence 4).
CDC GUIDELINES
• Providers should evaluate benefits and harms
with patients within 1 to 4 weeks of starting
opioid therapy for chronic pain or dose
escalation. Providers should evaluate benefits
and harms of continued therapy with patients
every 3 months or more frequently. If benefits
do not outweigh harms of continued opioid
therapy, providers should work with patients to
reduce opioid dosage and to discontinue opioids
(Category A, evidence type 4).
CDC GUIDELINES
• Before starting and periodically during
continuation of opioid therapy, providers should
evaluate risk factors for opioid related harms.
Providers should incorporate into the
management plan strategies to mitigate risk,
including considering offering naloxone when
factors that increase risk for opioid overdose,
such as history of overdose, history of substance
use disorder or higher opioid dosages >50 MME
are present (Category A, evidence type 4)
CDC GUIDELINES
• Providers should review the patients history of
controlled substance prescriptions using state
prescription monitoring program data to
determine whether the patient is receiving high
opioid dosages or dangerous combinations that
put them at high risk for overdose. Providers
should review PMP data when starting opioid
therapy for chronic pain and periodically during
opioid therapy for chronic pain ranging from
every prescription to every 3 months (Category
A, evidence type 4).
CDC GUIDELINES
• When prescribing opioids for chronic pain,
providers should use urine drug testing
before starting opioid therapy and
consider urine drug testing at least
annually to assess for prescribed
medications as well as other controlled
prescription drugs and illicit drugs
(Category B, evidence type 4).
CDC GUIDELINES
• Providers should avoid prescribing opioid
pain medications for patients receiving
benzodiazepines whenever possible
(Category A, evidence type
CDC GUIDELINES
• Providers should offer or arrange evidence
based treatment (medication assisted
treatment in combination with behavioral
therapies) for patients with opioid use
disorder (Category A, evidence type 3)
UNUSED MEDICATIONS
• DRUG DISPOSAL
ADVANCEMENTS
• Fentanyl vaccine
• Cocaine vaccine
• MAT Suboxone
• Chasing the dragon