How to intelligently prevent
opioid abuse
by GEORGE LUNDBERG, MD
AND MARIA A. SULLIVAN, MD, PHD | in MEDS | (FiDA blog bold)
Acute and chronic pain is bad.
Proper pain management is essential and has been strongly emphasized by the
American medical establishment for the past nearly two decades.
Simultaneously, during these years, both the quantity
of opioids prescribed by physicians and dentists has increased dramatically and
prescription
opioid abuse has escalated at an alarming rate among chronic pain
patients and the general population. Opioid analgesics now result in more American
overdose deaths than cocaine and heroin combined.
What should physicians do? For
treatment of chronic pain, non-opioid
analgesics should be the first-line agents.
Physicians and nurses must discuss with patients
common opioid side effects such as constipation and sedation, other risks such
as addiction and overdose, and potential long-term risks such as hyperalgesia
and sexual dysfunction.
Short-acting opioids such as Dilaudid (hydromorphone)
and Vicodin (hydrocodone/paracetamol) may be helpful for initial pain relief,
but longer-term dosing can lead to breakthrough pain and withdrawal, and these
agents carry a relatively high abuse potential.
Oxycontin
(oxycodone CR) is also widely abused, especially in rural areas; its
elevated dosage means it is highly addictable, and coverage by insurance makes
it cheaper than heroin.
Longer-acting opioid analgesics such as Suboxone
(buprenorphine), methadone, and fentanyl have a much lower abuse liability.
However, methadone is
found in more overdose deaths than any other prescription opioid and
should not be prescribed for opioid-naive patients. Because analgesic effects
of methadone are of shorter duration (6 to 9 hours) than its half-life (36
hours), levels may accumulate, leading to respiratory suppression or cardiac
events.
Patients should be instructed to keep controlled
substances safe in a locked location to prevent use or sale by others.
If a physician intends to prescribe opioids for
chronic pain, a narcotic protocol – medication contract, psychological
evaluation, and urine toxicology – should be considered. Monitoring both urine toxicology
and aberrant
behaviors will detect more opioid abuse than either strategy alone.
Combining a
clinical interview and the SOAPP (Screening and Opioid
Assessment for Patients with Pain) yields the highest sensitivity
(.90) for abuse detection.
A “universal
precautions” approach to minimizing risk includes asking patients
about history of substance abuse, written informed consent, and ongoing
reassessment of the benefits of opioid therapy. Clinicians can thus triage patients
to low-, medium-, and high-risk addiction potential. Treatment agreements
should delineate rules such as having no early refills and requiring urine
toxicology.
For patients who develop opioid addiction,
substitution with buprenorphine or another abuse-deterrent formulation and
adherence monitoring can be implemented.
The medical establishment should develop and use
effective analgesics with lower abuse potential. Current research efforts
to identify better methods to detect patients at heightened risk for developing
addiction should be supported.
All
prescribers of opioids must actively manage pain control while aggressively and
intelligently attempting to prevent opioid abuse.
George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal
of the American Medical Association. Maria A. Sullivan is an Associate
Professor of Clinical Psychiatry in the Division on Substance Abuse at Columbia
University and the New York State Psychiatric Institute.
So . . . those innocent patients who received prescription
pain medication (e.g. long-term maximum dose hydrocodone) will be side railed
into a "new" medical plan to EVALUATE their
pain/addiction level (eliminate the current prescription). How is this new program customized to a victim of a
failed implanted medical device (FDA MedWatch #5009052)? The cascading damage
of failed device, pharma evasion of untreated serious dry mouth side-effect on
dental health, medical abandonment, insurance abandonment, inaccessible
justice, and now potential coercion into withdrawal or alternate medication so
that the medical community can move on. How is this patient-centered? The
prescribing doctors need to experience this kind of treatment: they have
no concept.
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