Alice Messer, FNP-BC, DNP(c) 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 pre-existing 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