ATrain Education

 

Continuing Education for Health Professionals

Course Modules

  • Course Introduction
  1. Opioid Epidemic a National Emergency
  2. The Painful Numbers of Opioid Abuse
  3. Definitions of Use and Abuse
  4. Pharmacokinetics and Pharmacodynamics of Opioids
  5. Prevention and Screening Strategies
  6. Acute Treatment for Overdose
  7. Treatment Strategies for Long-Term Recovery
  8. Summary
  9. Resources and References
Return to Module View

Opioid Epidemic: How Did We Get Here and Where Do We Go Now?

  • Author:
    • Tracey Long, RN, PhD, MS, MSN, CDE, CNE, CHUC, COI, CCRN

      Tracey is a registered nurse who has worked in critical care, telemetry, and primary care for almost 30 years. She developed health education and diabetes programs in Spanish for local hospitals in Las Vegas, Nevada, where she now resides. Tracey earned a double bachelor’s degree in Nursing Science and Spanish from Brigham Young University, a master’s degree in Public Health Education at California College of Health Sciences, and an MSN in Nursing Education at UNLV. She completed her PhD in Nursing Education and Leadership. Tracey has served on the nursing faculty at the College of Southern Nevada and at Nevada State College. She has been a health-welfare missionary in Colombia and works with International Service Learning, taking nurses and students to Belize, Peru, Colombia, Costa Rica and other developing countries, where they offer medical clinics to rural communities. Her research interests are international health and nursing, simulation, cultural competency training, measuring effectiveness in education, and diabetes education. She served on the National Council of State Boards of Nursing for the National Nursing Simulation Study Team.

      As a freelance speaker Tracey earned the Educator of Excellence Award, and has been an invited keynote speaker for nursing school graduations, nursing career fairs, nursing webinars, and genealogy seminars. She has written three children’s health books as well as Climbing Family Trees: Whispers in the Leaves about researching genealogy. She married her college sweetheart and they have their own Brady Bunch of six kids, who teach her what’s really important in life! 

       

       

  • Contact hours: 1
  • Pharmacotherapy hours: 1
  • Expiration date: October 1, 2019
  • Course price: $0

Course Summary

If you are a healthcare professional, you have a role in our nation’s opioid epidemic. From those who prescribe to those who administer opioids, everyone plays a part in helping or hurting those seeking opioids for pain relief. This course discusses the causes, definitions of use and abuse, pharmacodynamics, and prevention and treatment strategies for this serious issue in healthcare.

The following information applies to occupational therapy professionals:

  • Target Audience: Occupational Therapists, OTAs
  • Instructional Level: Introductory
  • Content Focus: Category 1—Domain of OT, Client Factors Category 2—Occupational Therapy Process, Outcomes

Criteria for Successful Completion

80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.

Conflict of Interest/Commercial Support

Conflict of Interest/Commercial Support

Accredited status does not imply endorsement by ATrain Education Inc. or by the American Nurses Credentialing Center or any other accrediting agency of any products discussed or displayed in this course. The planners and authors of this course have declared no conflict of interest and all information is provided fairly and without bias. No commercial support was received for this activity.

Accreditation Information

Objectives: When you finish this course you will be able to:

  • Describe the government’s response to the opioid epidemic and continue to follow it.
  • Describe the incidence and prevalence of the opioid epidemic in America.
  • Explain the pharmacologic effects of opioids.
  • Define opioid use, abuse, addiction, and dependence.
  • Identify prevention and screening strategies for opioid misuse and abuse.
  • List treatment strategies for opioid misuse and abuse.

Opioid Epidemic a National Emergency

 

Thirty years ago, I attended medical school in New York. In the key lecture on pain management, the professor told us confidently that patients who received prescription narcotics for pain would not become addicted.

 

While pain management remains an essential patient right, a generation of healthcare professionals, patients, and families have learned the hard way how deeply misguided that assertion was. Narcotics—both illegal and legal—are dangerous drugs that can destroy lives and communities.

 

Thomas Frieden, MD, February 24, 2012
Former Director, CDC (Special to CNN)

The opioid epidemic is a problem the likes of which we have never seen.

President Donald Trump
CNN Politics, August 9, 2017

 

On March 29, 2017 President Donald Trump ordered the establishment of the Commission on Combating Drug Addiction and the Opioid Crisis, to be headed by New Jersey Governor Chris Christie. The final report was issued on November 1, 2017. Following is a summary of its recommendations.

Federal Funding and Programs

  1. The Commission urges Congress and the Administration to block grant federal funding for opioid-related and SUD-related activities to the states, where the battle is happening every day. There are multiple federal agencies and multiple grants within those agencies that cause states a significant administrative burden from an application and reporting perspective. Creating uniform block grants would allow more resources to be spent on administering life-saving programs. This was a request to the Commission by nearly every Governor, regardless of party, across the country.
  2. The Commission believes that ONDCP must establish a coordinated system for tracking all federally-funded initiatives, through support from HHS and DOJ. If we are to invest in combating this epidemic, we must invest in only those programs that achieve quantifiable goals and metrics. We are operating blindly today; ONDCP must establish a system of tracking and accountability.
  3. To achieve accountability in federal programs, the Commission recommends that ONDCP review is a component of every federal program and that necessary funding is provided for implementation. Cooperation by federal agencies and the states must be mandated.

Opioid Addiction Prevention

  1. The Commission recommends that Department of Education (DOE) collaborate with states on student assessment programs such as Screening, Brief Intervention and Referral to Treatment (SBIRT). SBIRT is a program that uses a screening tool by trained staff to identify at-risk youth who may need treatment. This should be deployed for adolescents in middle school, high school and college levels. This is a significant prevention tool.
  2. The Commission recommends the Administration fund and collaborate with private sector and non-profit partners to design and implement a wide-reaching, national multi-platform media campaign addressing the hazards of substance use, the danger of opioids, and stigma. A similar mass media/educational campaign was launched during the AIDs public health crisis.
Prescribing Guidelines, Regulations, Education
  1. recommends that HHS, DOJ/DEA, ONDCP, and pharmacy The Commission recommends HHS, the Department of Labor (DOL), VA/DOD, FDA, and ONDCP work with stakeholders to develop model statutes, regulations, and policies that ensure informed patient consent prior to an opioid prescription for chronic pain. Patients need to understand the risks, benefits and alternatives to taking opioids. This is not the standard today.
  2. The Commission recommends that HHS coordinate the development of a national curriculum and standard of care for opioid prescribers. An updated set of guidelines for prescription pain medications should be established by an expert committee composed of various specialty
  3. The Commission recommends that federal agencies work to collect participation data. Data on prescribing patterns should be matched with participation in continuing medical education data to determine program effectiveness and such analytics shared with clinicians and stakeholders such as state licensing boards.
  4. The Commission recommends that the Administration develop a model training program to be disseminated to all levels of medical education (including all prescribers) on screening for substance use and mental health status to identify at risk patients.
  5. 10.The Commission recommends the Administration work with Congress to amend the Controlled Substances Act to allow the DEA to require that all prescribers desiring to be relicensed to prescribe opioids show participation in an approved continuing medical education program on opioid prescribing.
  6. The Commission associations train pharmacists on best practices to evaluate legitimacy of opioid prescriptions, and not penalize pharmacists for denying inappropriate prescriptions.

For the complete report, click here.

 

chart: comparison of drug related deaths in Europe and US

Kristoff N. (2017). How to Win a War on Drugs. September 24, 2017, NY Times.

 

* * *

Bob, a 45-year-old construction worker was being treated in an acute care hospital for a broken femur repair and a low back work-related injury. The nurses offered narcotic analgesics around the clock, as ordered, to keep Bob comfortable. (Rather than offer any other comfort measures, it was just easier to draw up the narcotic to keep him from using the call light repeatedly.)

After he was discharged, Bob followed up with his primary care physician, who initially prescribed oxycodone and muscle relaxers in a limited supply and without refills per standard practice. Within one month, Bob returned complaining of constant pain, and he was given a new prescription for oxycodone. The monthly visits became routine and without additional assessments, offering alternative modalities or a narcotic use contract, the prescriptions continued to be written and filled.

The medications began to offer no further pain relief and Bob began supplementing with legal marijuana to provide relief of the initial back pain and the progressive physical craving for the opioid. He visited several other physicians to increase his supply and none of the providers were aware of his multiple visits and duplicated prescriptions.

Bob eventually advanced to street heroin and ultimately overdosed on the combination of opioids, which took his life.

What could have been done to avoid this needless loss of life?

What is the role of healthcare professionals in the prescribing and monitoring of opioid drugs?

What is the nurse’s role in the opioid epidemic?

What prevention and treatment strategies are available?

Not every opioid-related death is a stereotypical drug addict who is homeless and helpless. Opioid users include persons of any age, gender, religion, or culture who may have been prescribed opioids for pain control of injuries not their own fault. Often the desire for acute or chronic pain relief evolves to the need for stronger pain control and drug seeking behaviors driven by the basic desire for pain relief.

Unfortunately, opioid drug users also include those looking for entertainment through narcotic drug use and those who gradually become addicted. For example, compare these two users: one a teen looking for peer acceptance and entertainment and the other an educated healthcare professional seeking pain relief, and both have serous consequences from misuse of the powerful class of drugs known as opioids.

A 15-year old female overdosed at a high school party after being given street heroin laced with contaminants.

A 45-year old ER physician was caught writing her own prescriptions for oxycodone after suffering from chronic knee pain. Her licensed was suspended and she was then forced into rehabilitation under the terms of the medical board.

Healthcare professionals who are a part of prescribing or administering opioids need to be aware of the potential for abuse and misuse. Not only do they need to be well informed about the appropriate use and cautions for opioid use, but they need to be able to recognize its effectiveness, side effects, and overdose symptoms, and to recognize abuse in patients as well as their colleagues. Healthcare professionals are actually at greater risk than the general population for opioid abuse because of their access to the drugs.

What Are Opioids?

Opioids include codeine, fentanyl, hydrocodone, meperiden, hydromorphone, methadone, morphine, oxycodone, and heroin. Drugs from the opioids class are powerful analgesics and are used for pain management. Because they are powerful, and powerfully addicting, millions of people who use them can become physically and psychologically dependent or addicted to them. From 2000 to 2015, more than half a million people in the United States alone died from opioid drug overdoses.

Opioids are categorized as schedule 1 or 2 drugs by the Drug Enforcement Agency (DEA). A schedule 2 drug such as morphine means that, although it has been approved for medical treatment as an analgesic, it has high potential for strong psychological and physiologic dependence. It has been used for over one hundred years as an analgesic. Heroin is made by taking morphine, which is from the opium plant, and adding a chemical reagent that makes it more potent and potentially dangerous. Heroin is a schedule 1 drug and is not approved for any medical use because it is highly addictive.

Brief History of Opioids

So how did we get to this point of millions of Americans using and abusing opioids? The documented use of opioids began as early as 3400 B.C. in Mesopotamia, where they called it the “joy plant.” Opium was used for every medical malady including diarrhea, cholera, rheumatism, fatigue, and even diabetes by early Egyptians. Opium was regularly traded by the Turks and Arabs in the sixth century.

Opium Poppy Plant

image: opium poppy plant with flower

Source: Wikimedia Commons.

Opioid use became much more common in the early 1700s, when the British refined production from the Asian poppy plant that was grown during the British Crown Rule of India and sold in China. What became helpful as analgesia quickly became popular for treating every possible malady, and was even used as entertainment according to historical records of opium parties (Britannica, 2017).

British ships delivered 1,000 chests of opium into China in the 1760s and gradually increasing it to 4,000 chests in 1800, to eventually 40,000 chests in 1838. Opium was immensely popular in China and the desire for porcelain, silk, and tea was equally in demand in the West, so the trading continued. Alarmed by its powerful addicting properties to the Chinese citizens, the Chinese emperor Yongzheng (1722–1735) eventually prohibited the sale and smoking of opium, which led to opium wars with the Westerners (Britannica, 2017).

Opium trading eventually became more regulated and slowed during the communist reign in twentieth century China. Unfortunately, opium trading continued with new players, notably tropical growers and illegal importers from Central and South America to the United States. In the late 1800s, Bayer manufacturer created and sold heroin, and its misuse was rampant until regulations and taxes were designed to thwart its use. Then, after WWII and Vietnam, another wave of use and abuse crossed America with the resultant reflex to further regulate and tax its use (Britannica, 2017). The war on drugs has continued.

Pain as the Fifth Vital Sign

Concurrent with the increasing demand for opioids here in the United States was the medical profession’s increased interest in addressing patients’ pain. Pain was added as the 5th vital sign in 1996 and a movement to minimize all pain increased prescriptions for opioids.

Campaigns by pharmaceutical companies boasting the effectiveness of their drugs without side effects and added to the growth of prescriptions for opiates. These companies even created organizations with persuasive lobbyists to decrease barriers and regulations on opiate use. In 2007 the maker of Oxycontin (Purdue Pharma) was forced to pay over $6 million in fines for misleading claims about opioid safety.

Another cause for the increase in the opioid epidemic is the ease of creating the drugs chemically, including semisynthetic and fully synthetic drugs created in a laboratory by pharmaceutical companies. Creating heroin from morphine can be done in a home laboratory, thus contributing to the availability of street drugs. The demand for heroin by Americans continues to support the supply coming illegally from Central and South America into the United States.

 

Answer: B

Test Your Knowledge

Which of the following is a cause of the opioid epidemic?

  1. Artificial limitations to prescriptions
  2. Emphasis on treating pain aggressively
  3. Lack of self-discipline
  4. Belief that pain should be treated at all cost

Apply Your Knowledge

Did You Know . . .

Opium comes from the natural Asian poppy plant and is 10 times as potent as cocaine. Heroin (diamorphine) is 3 to 10 times as potent as opium or morphine. Heroin is illegally combined with a chemical reagent called acetic anhydride and often with other often-lethal contaminants to act as stabilizers.

Online Resources

YouTube: American Epidemic: The Nation’s Struggle with Opioid Addiction

https://www.youtube.com/watch?v=nNj89ohoYQ0

YouTube: Inside the Worst Drug-Induced Epidemic in U.S. History

https://www.youtube.com/watch?v=wtnuK1RysGc&t=3s

The Painful Numbers of Opioid Abuse

The Centers for Disease Control and Prevention (CDC) has declared the overuse and abuse of opioids an epidemic (Hedegaard et al., 2014; Rudd et al., 2016). Ninety-one Americans die every day from an opioid overdose (CDC, 2017). The United States consumes 99% of all the world’s hydrocodone, 80% of the world’s oxycodone, and 65% of the world’s hydromorphone prescription opiate supply. 25% of all workers’ compensation costs relate to opioids and $56 billion per year is spent on opioid abuse costs.

Trends of opioid overdose-related deaths have increased 5.5% annually, from 6 deaths per 100,000 people in the United States in 1999 to 16.3 in 2015. In adults aged 45 to 54 the death rate from drug overdose was the highest of all age populations showing a constant trend upward of 10% annual increase in abuse and deaths (NCHS, 2015). Clearly, America has an opioid epidemic that is claiming lives and lifestyles. Additional statistics, not as easily identified but very real, are the lost productive work hours and loss of meaningful lives, families, and marriages due to opioid abuse (ASAM, 2016).

 

Deaths by Age Cohorts 1999–2015

chart: overdose-related deaths by age

 

1Significant increasing trend, p < 0.005.
2Rate for age group 45–54 in 2015 was significantly hight than for any other age group, p < 0.001.
Notes: Deaths are classified using the International Classification of Diseases, Tenth Revision. Drug overdose deaths are identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14. Access data table for this figure at: https://www.cdc.gov/nchs/data/databriefs/db273_table.pdf#2.
Source: NCHS, National Vital Statistics System, Mortality.

 

Opioid drugs include:

Natural Opioids

  • Morphine
  • Codeine (only available in generic form)
  • Thebaine

Semi-synthetic

  • Hydrocodone (Hysingla ER, Zohydro ER)
  • Hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)
  • Hydromorphone (Dilaudid, Exalgo)
  • Oxycodone (OxyContin)
  • Heroin

Fully synthetic/manmade

  • Fentanyl (Actiq, Duragesic, Fentora)
  • Meperidine (Demerol)
  • Methadone (Dolophine, Methadose)
  • Tramadol
  • Levorphanol
  • Pethidine
  • Dextropropoxiphene

Whereas natural opiates come from the opium plant and the active ingredient is morphine, semi-synthetic opioids are those created in laboratories and include hydromorphone, hydrocodone, and oxycodone as well as the illegal drug heroin. All of these are called narcotics and are schedule II drugs, except for heroin, which is an illegal schedule I drug and hasn’t been approved for any medical use.

Substance abuse is global in scale and claims millions of lives worldwide. The number of people classified with drug user disorders has increased for the first time in six years (UNODC, 2014). Worldwide, over 250 million people between the ages of 15 and 64 used at least one illicit drug in 2014, which represents 5% of the world’s population. Over 207,000 deaths were reported to be drug related in the same year.

In the United States more than 29 million people over age 12 used cocaine, heroine, amphetamines, or opiates once in the year surveyed (World Drug Report, 2016). More than 200 million Americans aged 12 or over had used an illicit drug at least once in their lifetime and half of those had used an illicit drug within the past year (WHO, 2014).

 

Answer: C

Test Your Knowledge

Which of the following is NOT an opioid?

  1. Morphine
  2. Hydrocodone
  3. Cocaine
  4. Fentanyl

Apply Your Knowledge

You are a medical/surgical nurse and your patient is complaining of pain rated at 5 out of 10 who has orders for hydrocodone. What nonpharmacologic options do you have to help with pain reduction? How often do you try to offer those to your patients?

Is your healthcare facility supportive of your efforts to offer nonpharmacologic options for pain control?

Online Resources

YouTube: The History of Opioids

https://www.youtube.com/watch?v=4MIseokXcxY

YouTube: Terrifying Facts About The Current Opioid Addiction Epidemic

https://www.youtube.com/watch?v=Owjm9AKn4bg

Definitions of Use and Abuse

Clarifying the difference between dependence and addiction is important to better understand the issues in opioid use and abuse. Dependence is the physical tolerance of the drug that requires increased amounts of the drug to achieve the desired response. Withdrawal of the drug will result in physical symptoms such as shaking, tremors, nausea, and vomiting. Addiction is a behavioral disorder that refers to the emotional desire for the drug and the desired effects it brings, which often creates strong drug seeking behaviors. Generally, those who are dependent on opioids will vary between feeling sick without the drug and the desired high after taking the drug. Being addicted to the drug will motivate a person to do whatever it takes to get and take the drug to avoid the dreaded withdrawal symptoms.

Withdrawal symptoms include the following:

  • Intense drug cravings
  • Depression, withdrawal fears, anxiety
  • Sweating, watery eyes, runny nose
  • Restlessness, yawning
  • Diarrhea
  • Fever and chills
  • Muscle spasms
  • Tremors and joint pain
  • Stomach cramps
  • Nausea and vomiting
  • Elevated heart rate and blood pressure (NIDA, 2015; Kosten & O’Connor, 2013).

People at risk for opioid dependence and addiction are seen in every age, gender, ethnicity, and culture. Physical dependence varies. A genetic component has been identified that influences how quickly a person may slide from occasional use to physical need and addiction to the drug (Kreek et al., 2005). Susceptible populations have typically included the homeless, alcoholics, and those with personality or mental health disorders who look for a way to block the emotional pain of life stressors. Healthcare professionals, who experience great work stress, have a higher risk of becoming dependent or addicted to opiates following back or other injuries and having easier access to narcotics in their work setting (Kenna & Lewis, 2008).

 

Answer: C

Test Your Knowledge

What is the definition of dependence?

  1. A drug user who wants the drug for a party
  2. The drug user who depends on his dealer for a steady supply
  3. A person who uses the drug regularly and now physically depends on an increase of the drug
  4. The person who takes opioids occasionally for entertainment and to feel pleasure

Apply Your Knowledge

Q: What are the first symptoms you see when a patient has had too much oxycodone?
A: Change in level of consciousness and pinpoint pupils.

Online Resource

YouTube: CDC Releases New Statistics on Nation’s Opioid Crisis

https://www.youtube.com/watch?v=_IX45pNholM

Pharmacokinetics and Pharmacodynamics of Opioids

Analgesics are a class of drugs that help relieve the body from the sensation of pain by blocking chemicals in the pain sensor neurons of the brain. Other neurons throughout the body send messages to the brain on a multitude of topics (eg, temperature, pressure, pH).

Nociceptors, nerve receptors for pain, send messages of noxious stimuli to the brain that something is potentially hurting the body. Nociceptors send messages about such things as pressure, sharp objects, noxious smells, bad tastes, and pain and the brain interprets those for immediate response to protect the body.

Opioid Receptors

There are several neurotransmitters involved in pain signals, the main ones being glutamine and substance P. When noxious stimuli trigger the primary neuron through the skin or muscle, the message is relayed by a secondary neuron to the spinal cord’s dorsal root ganglion and toward the brain for interpretation. These chemical neurotransmitters are relayed to the thalamus in the brain and then onto the limbic system for an emotional response. Ideally, the message to the limbic area of the brain promotes learning so as to avoid the cause of the noxious substance in the future.

Opioids inhibit pain signals at multiple areas in this pathway. They affect the brain, the spinal cord, and even the peripheral nervous system. Opioids work on both directions of messages in the nervous system, including the ascending pathways in the spinal cord, which they inhibit, and the descending pathways, by which they block inflammatory responses to noxious stimuli.

Our bodies have three receptors called mu, kappa, and delta, that can be activated by opioid agonists like morphine, hydrocodone, or heroin. When mu receptors are activated, dopamine, the natural brain chemical for pleasure, is also increased. Pleasurable feelings are experienced as inherently worth repeating, which drives the user to repeat the drug use.

Opioid receptors are found on both the primary and secondary neurons, and when an opioid binds to these receptors no other pain signals are sent up to the brain—making opioids very effective against pain. In the brain, opioids cause sedation and decrease the emotional response to pain. Heroin, like morphine, passes through the liver and then is released back into the blood, where it crosses the blood–brain barriers. Heroin is converted to morphine where it connects with mu receptors, so fast that heroin is three times more potent than morphine.

Short-term sensations of opioids

  • Warmth sensation through skin and body
  • A feeling of heaviness in arms and legs
  • Pain relief
  • Dry mouth
  • Itchiness
  • Possible dry mouth
  • Drowsiness
  • Slowed heart functioning
  • Slowed breathing
  • Relaxation
  • Sense of well being

These opioid agonists come with additional noxious side effects. When a kappa receptor is stimulated, it can also produce hallucinations, anxiety, and restlessness. Delta and mu receptors can cause respiratory depression, because as the midbrain is stimulated it suppresses the body’s ability to detect carbon dioxide levels in the body, which is the main stimulus for breathing.

Other negative side effects include constipation, sedation, nausea, dizziness, urinary retention and tolerance. Tolerance is the requirement of the body for increased amounts of the drug to reach its desired effects; this is why opioids can become addictive as the person continues taking more and more of the drug to achieve the desired pain relieving and sedating effects (Dunphy & Winland-Brown, 2016). The key ingredient in opium is morphine, which began to be produced formally by the pharmaceutical company Merck. It was also discovered that when administered by IV, morphine is 3 times more potent than administered by other methods such as smoking or snorting.

Long-term Side Effects of Opioid Use

Long-term use of opioids has been shown to cause deterioration of the brain’s white matter and includes effects of insomnia, chronic constipation, sexual dysfunction, irregular menstrual cycles in women, and kidney disease, as well as physical damage resulting from administration techniques such as snorting, smoking, or IV drug use.

Although cocaine and morphine both have effects on the neurotransmitter dopamine, they work in different ways. Whereas the opioids increasing dopamine stimulation, cocaine blocks the reuptake of existing dopamine and makes it last longer, producing a longer state of pleasure. Both opioids and cocaine do, however, influence the brain’s interpretation of pleasure—reinforcing the repeated drive to get the drug. In addition to short-term withdrawal symptoms,

Long-term opioid use causes

  • Decreased ability in decision making
  • Decreased ability for self-reflection and discipline
  • Decreased ability to respond to stress effectively

 

Answer: C

Test Your Knowledge

How do opioids work?

  1. They block pain at the site of the noxious signal.
  2. Opioids block the neurotransmitter dopamine.
  3. Opioids bind to receptors in the peripheral and CNS to block pain signals.
  4. Opioids increase serotonin throughout the brain.

Apply Your Knowledge

Q: What is the fastest acting opioid that is used in medicine for pain relief? How is it administered?
A: IV morphine and fentanyl

Online Resources

YouTube: The Science of Opioids

https://www.youtube.com/watch?v=AqDo4LiKz-c

YouTube: Opioids Work Really, Really Well. . .But We Don’t Know Why

https://www.youtube.com/watch?v=BlkGgF2bwDY

Prevention and Screening Strategies

 

CVS pharmacies announced today that they will no longer fill prescriptions for opioids for more than one week without a repeat prescription from the physician. This will affect their nearly 100,000 Caremark members and they will counsel others as well.

 

NBC News TV, September 22, 2017

 

Prevention

Of course the best treatment is prevention, which means decreasing the availability or prescriptions for opioids in the first place. The Food and Drug Administration (FDA) has produced guidelines for effective pharmacologic use of opiates, which include the identification of persons at risk, assessing a patient’s benefit vs. risk, and developing and using tools to decrease risks of opiate prescription, including contracts for pain management and standards of required 30-day physician visits before new prescriptions can be refilled.

Prevention strategies include:

  • Patient education regarding use of opiates
  • Pain contract signed by patient to agree to terms of drug use
  • Prescription monitoring programs to detect multiple use of pharmacies and physicians for opiates
  • Detection of inappropriate prescribing of opioids
  • Photo identification to pick up opioid prescriptions
  • Urine toxicology screening for employees
  • Safe disposal of unused opioids
  • Referrals to pain and addiction specialists
  • Use of semi-synthetic opioid alternatives

Patient education regarding the use of opiates, and truly all prescription medications, is essential for them to understand the need for the drug, its side effects and adverse effects. An additional pain contract, which outlines the parameters for the use of the drug, may be included with the patient education. Especially when used for chronic pain management, patients should be partners with the prescriber to outline when the drug will be used and for how long.

Prescription monitoring programs include detection systems in pharmacies and the local district that identify patients who have filled a narcotic prescription. In many states, photo ID is already required for the purchase of cigarettes or alcohol and could become a beginning point to dissuade unauthorized and high-frequency prescription use. According to the National Alliance for Model State Drug Laws (NAMSDL, 2017), currently 85% of states require ID for narcotic prescription use. Some drugstores even run the name of a client picking up a narcotic prescription through a drug monitoring data system for alerts. The challenge is for busy pharmacists to take the time to use the monitoring system and for all of us to be patient as the process is completed.

Possible red flags that could lead to prescription denial:

  • A pain medication not previously filled by the pharmacy
  • A “new” doctor writing a prescription for the same pain medication
  • A doctor writing a prescription who is not in a “reasonable geographic location” near the pharmacy
  • A patient paying for a prescription in cash
  • A patient seeking an early refill of a prescription
  • A patient seeking an “excessive” number of pills
  • A patient taking the same pain medication for more than 6 months

Another strategy includes receiving prior authorization before opiates can be filled. In 2007 the FDA passed an amendment to create a patient registry for opioids. In 2012 Blue Cross Blue Shield began to require prior authorization for more than a one-month supply of opioids in a two-month period. By this simple process alone, in the state of Massachusetts, the number of opioid prescriptions was decreased by more than 6,500,000 pills in one year (Boston Globe, 2012).

Safe disposal of opioids is a challenging issue because many people believe that flushing them down the toilet is appropriate, which it is not. Public education and awareness programs must also include safe medication disposal, such as mixing with used coffee grounds, dirt, or kitty litter and placing in a sealed container to dispose of in the garbage. Used opioid patches should be folded in half on the sticky sides and disposed of in a sealed container in the garbage.

Screening Tools for Addiction

Several screening tools are available to help clinicians identify when a patient taking opioids may be experiencing dependence or addiction.

SBIRT

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs” (SAMHSA, 2016). The SBIRT model was inspired by a recommendation from the Institute of Medicine to increase community-based screening for health risk behaviors, including substance use.

SBIRT is an early and brief intervention of 15 to 30 minutes and billable to Medicare/Medicaid. The screening and referral to treatment includes a patient encounter, history, physical examination, clinical diagnosis, and plan for care specific to the concern of substance abuse (other than for those patients already identified with severe substance abuse). The SBIRT screening tool can be as simple as asking several key questions of patients receiving narcotics and opioids at every doctor’s office visit.

Opioid Risk Tool

The Opioid Risk Tool is another brief screening tool of questions to help identify a patient at increased risk for dependence and abuse. Currently no one tool has been identified to be better than any others, nor is any one tool sufficient to identify drug behaviors of chronic pain patients using opioids (Turk et al., 2008).

 

Answer: B

Test Your Knowledge

What is the SBIRT screening tool?

  1. A form completed to assess for risk for drug abuse.
  2. A brief intervention billable to Medicare/Medicaid.
  3. Used to admit a patient to a rehab facility for drug abuse.
  4. The history and physical used to assess patients for drug abuse.

Apply Your Knowledge

In the case presented at the beginning of this course, what steps could have been done to help identify the patient as at risk for opioid addiction and to avoid the overdose?

Online Resources

YouTube: The Clinical Assessment of Substance Use Disorders—Role Modeling the Initial Visit

https://www.youtube.com/watch?v=YqsGS6kvVrY

YouTube: The SBIRT Process (role model)

https://www.youtube.com/watch?v=hqt2CuvyiXc

YouTube: The SBIRT Audit Screening Questions

https://www.youtube.com/watch?v=RHcalohcunU

Article: Strategies to Prevent Opioid Misuse, Abuse, and Diversion that May Also Reduce the Associated Costs

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106581/

Acute Treatment for Overdose

Treatment for opioid abuse generally starts with treatment of withdrawal in the acute phase. Managing symptoms of overdose and preventing death are the first objective. Securing an airway and supporting the patient during the tremors, seizures, hypertension, nausea, vomiting, and pain are often handled in an ED or medical/surgical setting.

Nalaxone

Naloxone (Narcan) can be used for reversal of opioid overdose and is available in IV, SQ, IM, and nasal routes. If a patient is unconscious, follow the ABC’s of emergency response such as calling 9-1-1, checking for a pulse, securing an open airway, and providing rescue breaths. Give the first full dose of naloxone and continue rescue breaths. If the patient doesn’t respond give the second full dose of naloxone. Patients will often respond quickly and be confused and possibly combative. Monitor the patient after recovery with naloxone to prevent another dose of an opioid and follow up with further medical attention.

Methadone

Using pharmacologic blocking agents is helpful in stopping the opioid overdose. Antagonist medications block opioid receptors so that the desired effect is no longer active. Two opiate substitution medications are currently available in the United States—methadone and levomethadyl acetate—but are only available in strictly regulated environments where medication is received under clinical observation and limited outpatient use (Dowell et al., 2016). Methadone and buprenorphine are synthetic opioid agonists and act on the same mu receptors that opioids activate; therefore, they have been a popular treatment for addiction that is known as opioid substitution therapy (OST). Methadone has a slow onset of action and long elimination half-life of about 24 hours. A longer-acting opioid receptor agonist is buprenorphine, a partial opioid agonist that can reduce cravings and symptoms of withdrawals.

These drugs can be taken less frequently and can help wean a patient from the more fatal opioids. Control trials show that they are more effective than a placebo and can help decrease fatalities from opioids. Access to these drugs is still dependent upon physician-controlled prescribing or treatment programs (but see below for states allowing further access) (Schuckit, 2016).

Getting into approved treatment programs, where these drugs can be given and monitored closely, in combination with behavioral therapy, is often difficult, expensive, and not approved by insurance companies. The strict control of these opiate-substitution drugs is necessary because they do produce a euphoric sensation like the opiates and there is a concern for creating a new market of illicit use. These medications can be given in sublingual, oral, and even intranasal forms. These opioid antagonist drugs act as competition for the mu receptors and, ideally, block the effectiveness of other opiates.

Ten states do allow family members and friends to be trained in giving naloxone for a suspected drug overdose. The following states offer training for naloxone use:

  • California
  • Connecticut
  • District of Columbia
  • Illinois
  • Massachusetts
  • New Mexico
  • New York
  • North Carolina
  • Rhode Island
  • Virginia
  • Washington State

 

Answer: A

Test Your Knowledge

What is the antidote for an opioid overdose?

  1. Narcan
  2. Flumazenil
  3. Mucomyst
  4. Atropine

Apply Your Knowledge

What is your facility’s process for treatment of an opioid overdose? Do you know how to use Narcan?

Online Resources

YouTube: Using Nasal Naloxone to Reverse Opiate Overdose

https://www.youtube.com/watch?v=FZpgjRBby_M

YouTube: Coming back from the dead with Naloxone

https://www.youtube.com/watch?v=oWopsRaeY6M

Treatment Strategies for Long-Term Recovery

One big challenge with opioid use is its effectiveness against pain, and pain is very real. Long-term treatment relies on pharmacologic therapy and behavioral therapy. The objective of treatment is to reduce the dependence and addiction on opioid drugs and thus to decrease the opioid-related deaths and mortality. Clinical studies show behavioral modification isn’t effective on its own because the body has physical dependence that must be addressed. Opioid abuse is not an ethical or moral addiction, but rather a physiological response to the need for opioid receptor activation.

Physical withdrawal is painful and difficult, and those with opioid addiction will do anything to avoid it. With careful management, a person can successfully overcome the physical withdrawal; however, the psychological withdrawal is often more difficult and requires continual emotional support. Programs such as Alcoholics Anonymous can help guide the person through a series of steps towards independence from opioids, drugs, and pain.

Pain clinics are a newly developed specialty that allows patients suffering from chronic pain to work with a pain specialist for more effective management using a variety of modalities. It is estimated that at least 100 million Americans live with chronic pain. Pain clinics can offer help by focusing on procedures that deal with specific pain (eg, neck, lower back pain). They can also approach pain in an interdisciplinary way involving psychologists, physical therapists, nutritionists, and occupational and vocational therapists, in addition to physicians and nurses. They can suggest other modalities such as acupuncture, biofeedback, cognitive behavioral therapy, water therapy, massage, and meditation as options for chronic pain in lieu of opioids. Both patient education and prescriber need to include these alternative treatment strategies.

Recognition of opioid use within healthcare professionals has been addressed by the National Council of State Boards of Nursing. A free educational webinar for understanding substance use disorder and help in identifying signs of opioid use is available to nurses and managers. The webinar also outlines a system for helping professionals into therapy and recovery. Click here to access the webinar.

 

Answer: C

Test Your Knowledge

Which of the following is NOT a strategy to help with chronic pain and opioid use?

  1. Physical therapy
  2. Massage therapy
  3. Tapering opioids gradually over many months
  4. Nutrition therapy

Apply Your Knowledge

How can you be an advocate to improve pain control without the use of opioids?

Online Resource

https://www.youtube.com/watch?v=WMIQ6ChhZnw

Summary

Our nation’s opioid epidemic is complicated and concerning. Thousands of lives are being lost needlessly due to opioid addiction and overdose. Education of prescribers and patients is desperately needed. Legislation can help to regulate opioids available on the market and how they may be used.

States must implement availability and training for the use of naloxone and opioid agonists for overdose and weaning. Healthcare professionals must learn to collaborate with pharmacists, nutritionists, and behaviorists who work with those who have chronic pain to offer more options for pain management. Schools and public officials such as law enforcement must be enabled to improve security that will dissuade drug sales.

These proposed strategies to fight our national war on drugs are at various stages of development, and implementation can take time. The cost to implement programs, educate stakeholders, and evaluate any negative consequences to appropriate treatment plans for pain is considerable but necessary. Become an advocate for decisive government action to address this opioid epidemic.

In the meantime, small efforts can save lives. Your effort to learn more about the opioid epidemic is a beginning!

Resources and References

Resources

American Heart Association

eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf

American Pain Society

americanpainsociety.org/education/guidelines/overview

American Society of Addiction Medicine

www.asam.org/quality-practice/practice-resources/treatment
The ASAM Criteria; Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition.

Centers for Disease Control and Prevention (CDC)

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
www.cdc.gov/drugoverdose/prescribing/guideline.html

Diagnostic and Statistical Manual of Mental Disorders (DSM-V)

 

Drug Enforcement Administration, Office of Diversion Control

www.deadiversion.usdoj.gov

Medication Assisted Treatment

http://www.samhsa.gov/medication-assisted-treatment

National Institute on Drug Abuse (NIDA)

https://www.drugabuse.gov/

Ohio Physicians Health Program

www.ophp.org

National Institutes of Health (NIH)

https://www.nih.gov/news-events/news-releases/hhs-leaders-call-expanded-use-medications-combat-opioid-overdose-epidemic

Substance Abuse and Mental Health Services Administration

Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration.

www.samhsa.gov/treatment/substance-use-disorders
www.samhsa.gov/medication-assisted-treatment

References

American Society of Addiction Medicine (ASAM). (2016). Opioid Addiction, 2016 Facts and Figures. Retrieved from http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf.

Boston Globe. (2012). Blue Cross Cuts Back on Pain Prescriptions. Retrieved from https://www.bostonglobe.com/metro/2014/04/07/state-largest-health-insurer-cuts-painkiller-prescriptions/UAgtbqJL0XPrsNASuJ27sJ/story.html.

Centers for Disease Control and Prevention (CDC). (2017). Understanding the epidemic. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html.

Chen L, Hedegaard H, Warner M. (2014). Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011. NCHS data brief, no 166. Hyattsville, MD: National Center for Health Statistics. Retrieved September 4, 2017 from https://www.cdc.gov/nchs/products/databriefs/db166.htm.

Drash, Wayne. (2017). “Our citizens are dying. . . .” CNN, August 1, 2017, with Dan Merica and others.

Dowell D, Haegerich T, Chou R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. MMWR Recommendations Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

Dunphy L, Winland-Brown J. (2016). Primary Care: The Art and Science of Advanced Practice Nursing, 5th ed. Philadelphia: F.A. Davis Company.

Encyclopedia Britannica. (2017). Opium Wars. Retrieved August 28, 2017 from https://www.britannica.com/topic/Opium-Wars#ref632577.

Hahn K. (2011). Strategies to prevent opioid misuse, abuse and diversion that may also reduce the associated costs. American Health Drug Benefits 4(2). Mar-Apr. Retrieved 5 September 2017 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106581/.

Hedegaard H, Chen LH, Warner M. (2014). Drug-poisoning deaths involving heroin: United States, 2000–2013. NCHS data brief, no 190.

Kazan, Olga. (2017). “The interim report also recommended. . . .” July 31, 2017, NY Times.

Kenna G, Lewis D. (2008). Risk factors for alcohol and other drug use by healthcare professionals. Substance Abuse Treatment Prevention Policy. Retrieved 4 September 2017 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2265282/.

Kosten T, O’Connor P. (2013). Management of drug and alcohol withdrawal. New England Journal of Medicine 348:1786–95.

Kreek M, Nielsen D, Butelman E, LaForge K. (2005). Genetic influences on impulsivity, risk taking, stress responsibility and vulnerability to drug abuse and addiction. Neurobiology of Addiction. Nature Neuroscience. Retrieved September 4, 2017 from https://www.researchgate.net/profile/David_Nielsen/publication/7514762_Genetic_Influences_on_Impulsivity_Risk_Taking_Stress_Responsivity_and_Vulnerability_to_Drug_Abuse_and_Addiction/links/09e41513114210281a000000/Genetic-Influences-on-Impulsivity-Risk-Taking-Stress-Responsivity-and-Vulnerability-to-Drug-Abuse-and-Addiction.pdf.

National Alliance for Model State Drug Laws (NAMSDL). (2017). Retrieved from http://www.namsdl.org.

National Center for Health Statistics (NCHS). (2017). Drug overdose deaths in the United States 1999–2015. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db273.htm.

National Institute on Drug Abuse (NIDA). (2015.) Prescription Opioids and Heroin. Retrieved 28 August 2017 from https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-abuse-heroin-use/introduction.

Rudd RA, Seth P, David F, Scholl L. (2016). Increases in drug and opioid- involved overdose deaths—United States, 2010–2015. MMWR Rep 65:1445–52. Retrieved from https://www.cdc.gov/mmwr/ volumes/65/wr/mm655051e1.htm.

Schuckit M. (2016). Treatment of Opioid Use Disorders. NEJM 375(4):357. Retrieved September 1, 2017 from http://www.nejm.org/doi/full/10.1056/NEJMra1604339#t=article.

Substance Abuse and Mental Health Services Administration(SAMHSA). (2016). Screening, Brief Intervention, and Referral to Treatment (SBIRT). Retrieved from https://www.samhsa.gov/sbirt.

Substance Abuse and Mental Health Services Administration(SAMHSA) and U.S Department of Health and Human Services Health Resources and Services Administration(HRSA) (2016). SBIRT: Screening, Brief Intervention, and Referral to Treatment. Retrieved 1 September 2017 from http://www.integration.samhsa.gov/clinical-practice/sbirt.

Turk D, Swanson K, Gatchel R. (2008). Predicting opioid misuse by chronic pain patients: A systematic review and literature synthesis. Clinical Journal of Pain 24(6). Pp 497–508. Retrieved September 5, 2017 from http://journals.lww.com/clinicalpain/Abstract/2008/07000/Predicting_Opioid_Misuse_by_Chronic_Pain_Patients_.4.aspx.

United Nations Office on Drug and Crime (UNODC). (2014). Number of drug dependent adults up for first time in six years, now at 29 million: UNODC World Drug Report 2016. Retrieved from https://www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf.

UNODC Research. (2016). World Drug Report 2016. Retrieved from https://www.unodc.org/doc/wdr2016/WORLD_DRUG_REPORT_2016_web.pdf.

World Health Organization (WHO). (2017). Access to buprenorphine, methadone and oral morphine. Retrieved 28 August 2017 from http://www.who.int/hiv/amds/controlmedicine/en/.

World Health Organization (WHO), Substance Abuse and Mental Health Services Administration. (2014). Global Status Report on Alcohol and Health. Retrieved from https://books.google.com/books?hl=en&lr=&id=HbQXDAAAQBAJ&oi=fnd&pg=PR2&dq=Substance+Abuse+and+Mental+Health+Services+Administration+2014+More+than+200+million&ots=PbnCBiT3vH&sig=Rq28xiz4Y1XVuYnErM98Br_ry0Q#v=onepage&q&f=false.