Safe Opioid Prescribing in the Era of Overdose
LAS VEGAS — The number of opioid prescriptions filled in US pharmacies has tripled since the early 1990s, skyrocketing from 76 million in 1991 to 219 million in 2001.1 During this time period, emergency department visits from opioid misuse or abuse and opioid-related drug overdose deaths also rose sharply.
Continuing the upward trajectory, emergency department visits attributable to opioids increased from 600,000 to more than 1.2 million from 2004 to 2010, and overdose deaths have quadrupled from 4000 to more than 12,000 annually from 1999 to 2010, according to data from the Substance Abuse and Mental Health Services Administration.2
“As a result many states are enacting legislation to ensure appropriate, safe opioid prescribing,” said Brett Badgley Snodgrass, MSN, APRN, FNP-C, of Comprehensive Primary Care in Bartlett, Tennessee.
“Safe prescribing is of utmost importance, primarily to decrease diversion and abuse, but also to make it as safe and appropriate for our patients,” she said.
To ensure safe and effective chronic pain management, urine drug testing, risk stratification, and pharmacogenetic testing are also paramount.
“Drug screening is one of the elements we use in guiding our prescriptive habits when we're talking about opiates or controlled substances. It absolutely should be used in practice; how often depends on state mandates, the individual prescriber, and the patient,” Ms. Snodgrass said.
Drug testing helps providers determine if patients are taking their medications as prescribed, and also if they are taking other drugs that may interfere with their medications. A variety of screening methods are available, including urine analysis, blood immunoassays, and gas chromatography/mass spectrometry (GC/MS).
“Urine drug screening is one of the easiest and most reliable ways to obtain information on drug use. It can be performed quickly, so you can perform a point-of-care test and have some working knowledge of what is in that patient's urine when he or she leaves your office,” Ms. Snodgrass said.
When interpreting point-of-care test results, clinicians should assess the risk of false positives or negatives and should not make definitive decisions based on findings. If a urine drug test yields an unexpected finding, providers should limit the provision of the opioid to a 7- to 14-day period.
Clinicians should also be aware that some medication use or abuse may go undetected on a point-of-care test. Prescription drugs such as fentanyl, oxycodone, and carisoprodol are often omitted, certain opioid normetabolites may not react (typically <0.1%), and high thresholds are typically used in point-of-care tests.
“Take into account what's going on with the patient when you consider drug testing. If they are a higher-risk patient, then you should perform urine drug screening more often,” Ms. Snodgrass said.
Confirmation testing with more accurate methods such as GC/MS should be performed prior to making a final care decision, she advised.
It is also important for clinicians to monitor patient response to treatment, due to patient-related variations in drug metabolism that can result in wide fluctuations in clinical effect.
Genomic testing to detect genetic predispositions—such as allelic variation in the CYP2D6 and CYP2C19 genes, which can markedly increase or decrease drug metabolism—is a new trend in opioid management.
“Genomics can improve diagnostic and prescribing accuracy and speed,” Ms. Snodgrass said. “It helps with patients who are difficult to treat: those for whom no medications work, those who become very sedated with low doses of medication, and those who are on high doses and are still not getting appropriate effects with appropriate dosing.”
Weaning is another key aspect in managing patients taking opioids, either as a natural course of therapy when pain scores decrease and a patient has recovered or when a patient is displaying aberrant or divertive behavior.
Signs of aberrant behavior include doctor shopping, multiple instances of dose escalation, failure to comply with dosing instructions, inappropriate drug testing results, and obtaining opioids from multiple providers.
“Another reason for which you would wean is if a patient is not getting appropriate pain relief from higher doses and you've tried to titrate them appropriately to a dose that should be providing adequate relief,” Ms. Snodgrass said.
No matter what the reason, the clinician's main goal during opioid weaning should be preventing withdrawal symptoms. Most patients can have their opioid treatment tapered with a 10% to 20% weekly decrease.
It is imperative to outline the reasons for weaning and to provide written instructions for the weaning process in a provider-patient agreement signed by the patient.
During the weaning period, patients should undergo a urine drug test at each visit to monitor progress. Tapering can be discontinued once a drug screen is negative for the product being weaned.
If further pain management is necessary, the clinician should consider rotation to another opiate or perhaps other nonopioid alternatives.
“Treating pain is not synonymous with opiate use. We need to consider all other alternatives—such as anti-inflammatory medications, anticonvulsants, and mood modulators—when we are prescribing,” Ms. Snodgrass said. “We should also consider lifestyle therapies such as yoga, exercise, and acupuncture. We have evidence-based information that shows us that those things work.”
On the flip side, she added that healthcare providers should not be afraid to use an opioid when it is appropriate. Some patients truly have no other options, such as elderly patients for whom other medications are contraindicated and can actually have worse outcomes than treatment with opioids. For these patients, Ms. Snodgrass advised starting with a low dosage and titrating upward very slowly.
- IMS Institute for Healthcare Informatics. National Source Prescription Audit, Vector One.
- Substance Abuse and Mental Health Services Administration (SAMHSA). The DAWN report. July 2, 2012. Available at: http://www.samhsa.gov/data/sites/default/files/DAWN096/DAWN096/SR096EDHighlights2010.pdf. Accessed August 14, 2015.