Nonmedical Prescription Opioid Use and Use Disorders Among Adults Aged 18 Through 64 Years in the United States, 2003-2013

Opioid abuse has become a ubiquitous problem in the United States, one that leads to violence, pilfering, negligence, and all of the other vices associated with drug abuse. A unique aspect of painkiller abuse is the fact that the drugs are often obtained illegally from medical professionals instead of shady street corner dealers. Studying the patterns of opioid abuse are crucial to understanding the role that healthcare providers, especially pharmacists, can play in stopping this epidemic.

This particular study produced two interestingly yet insightfully contradictory results. It found that nonmedical use of prescription opioids decreased over the duration of this study, but the prevalence of prescription opioid use disorders increased. This means that although recreational use of prescription opioids is decreasing in popularity (albeit likely more due to the increased availability of heroin in recent years than any sort of anti-drug abuse policy), the symptoms of abuse are increasing in frequency. Essentially, people are still abusing prescription opioids at increasing rates, they either do so under the veil of a false or obsolete diagnosis, or they truly have an abuse problem relating to the severity of the pain which they experience.

This study highlights the immense importance which the pharmacists and physicians have in preventing and alleviating prescription drug abuse. Abuse through medically prescribed opioids is often preventable, and can be prevented by playing an active role in counseling patients on these risky drugs. Pharmacists play an integral role in preventing drug abuse.

Han B, Compton WM, Jones CM, Cai R. Nonmedical prescription opiod use and use disorders among adults aged 16-64 years in the United States, 2003-2013. Jama. 2015: 314(14): 1468-1478.

Prescription medication misuse among opioid dependent patients seeking inpatient detoxification

The goal of this article was to examine the extent to which patients who are opioid dependent and seeking detoxification are misusing other treatments such as clonazepam and gabapentin.  The study tested 196 patients.  Of the 196 patients, 162 had opioid dependency.  The data showed that of the patients who had suffered from opioid dependency were much more likely to misuse medication than those suffering from alcohol dependency (30% vs 0%).  Of the patients using opioids, 28% of the patients used higher amounts of the medication than prescribed.  They used such medication as gabapentin, clonazepam, and and pregabalin.  This study concluded, that despite the nonaddictive nature of some drugs they were still misused drastically by opioid dependents.

This article is interesting to me because it specifically touches on the possible addictive nature of gabapentin.  This is interesting because gabapentin is just starting to become a controlled substance due to its recent abuse in the past years.  This article provided some insight onto how a seemingly safe drug could become abused and lead to its future controlled status.

Wilens T, Zulauf C, Ryland D, et al. Prescription medication misuse among opioid dependent patients seeking inpatient detoxification. American Journal on Addictions. 2015; 24(2): 173-177.

The type and prevalence of the use of analgesics among inpatients in a geriatric psychiatry department

There is a strong correlation between and pain and mental disorders.  So it is expected that patient in psychiatric hospitals will be on some form of pain medication.  This study was done on 89 patients aged 68 or older.  There were 51.7% of the patients use analgesics.  Paracetamol was the most used drug followed by opioids.  This study concluded that analgesics were associated with adverse effects and so the less used on patients the better.  Thus, the study confirmed that analgesics were being used too frequently and should be addressed.

I have some disagreements with this article.  The amount of pain medication used on patients is a controversial subject.  Personally, I believe that pain medication is a necessary evil.  Better to deal with some adverse side effects than to deal with constant pain and analgesics are non-addictive for the most part.  Especially, since these are geriatric patients I believe that their comfort level should take top priority.  Overall, I believe this article to be eye-opening to the beliefs about pain medication in the hospital setting.

Østergaard PJ, Gustafsson LN, Høyer EH, Munk-Jørgensen P. The type and prevalence of the use of analgesics among inpatients in a geriatric psychiatry department. Therapeutic Advances in Psychopharmacology. 2016;6(1):13-21. doi:10.1177/2045125315619557.

Opioid Pharmacokinetics-Pharmacodynamics Clinical Implications in Acute Pain Management in Trauma

Pain management is a tough puzzle that faces many health care providers especially those in the emergency room. Trauma is the most common reason for someone to go to the emergency room and therefore opioids are some of the most commonly prescribed medications in the ER. But despite being so commonly used, opioids are very complex drugs that can be difficult to deal with. The first question that needs to be answered is whether or not an opioid is needed. Once this has been decided, the next question is which one. With so many opioids with almost identical mechanisms of action, how do doctors and pharmacists decide which one is the most appropriate?

 

In a review article composed by Mackenzie et al, they addressed this difficult decision by reviewing primary articles about the pharmacokinetic and pharmacodynamics profiles of morphine, hydromorphone and fentanyl. They found differences in each drug’s onset of action, their duration of action as well as the effects of titrating doses to achieve optimal pain relief. They ended up breaking down the profile of each drug and showing how they should be used to treat different types of pain. Fentanyl for a quick onset of acute pain, morphine for long term constant pain management, and hydromorphone for pain similar to morphine but best used without a loading dose.

 

This study showed that by investigating opioids Pk and Pd profiles, we can learn more about which situations call for which opioids. By knowing these facts, prescribers will be able to better customize a patients’ regimen to suit his or her needs. Should we be more interested in the pharmacokinetics of drugs? What about non-opioids?

 

Mackenzie M, Zed P, & Ensom M. Opioid pharmacokinetics-pharmacodynamics: clinical implications in acute pain management in trauma. Ann Pharmacother, 2016;50(3):209-218.

 

The Burden of Opioid-Induced Constipation: Discordance Between Patient and Health Care Provider Reports

Opioid medications are the most commonly prescribed medications for the treatment of chronic non-cancer pain.  However, the side effects and risks of addiction often prevent problems with patients with long term use of opioids.  In particular, opioid-induced constipation (OIC) is one of the most common side effects that impact patient quality of life, with patient surveys suggesting that as many as 17-67% of opioid patients experiencing GI immobility while on the medication.  Although this is a commonly recognized issue related to opioid therapy, there appears to be a lack of communication between patients and physicians about treatment and the role it plays in patient quality of life.

A recent study published on behalf of AstraZeneca Pharmaceuticals attempted to look at the prevalence of OIC, and the differences in patient and provider perception of the issue.  The researchers performed a perspective, longitudinal cohort study on 489 patients being treated with opioids for chronic pain in the U.S, Canada, U.K., and Germany.  Patients were selected based on chronic pain conditions that would be treated for >6 months, diagnosed with OIC based on patient reported symptoms.  Both patients and health care providers were asked to complete online surveys to assess their experience with OIC, quality of life, treatment options, concerns, and patient-provider interaction.

The results of the study showed that most providers reported discussing the potential for OIC and its impact on the patients medication experience.  However, just over half of patients reported disclosing instances of OIC with their doctor.  Most patients took OTC laxatives to cope with the OIC, and many reported lower quality of life.  Some patients reported lowering their opioid dose to alleviate OIC symptoms, but reported a corresponding increase in their level of chronic pain.  There was a reported lack of communication between patients and providers about the problem, with both sides reporting confusion over who was the anticipated initiator of the conversation.  There was also a lack of understanding from patients in available options for OIC treatment, as well as provider reported differences in priority of OIC between patients and their physicians.  The study concluded that there is a noticeable rift between patients and their providers over the perceived impact that OIC has on pain management.  They believe that an increase in communication related to opioid side effects, and resolution discussions will help lower patient anxiety over symptoms and increase quality of life without sacrificing pain management.

This problem clearly highlights some of the issues that still plague the pain management care field.  Clearly there is a communication issue between patients and their doctors that needs to be resolved in order to reduce OIC incidence and impact on pain therapy.  As pharmacists, we have an opportunity to address concerns with OIC, offer medication treatment options, and open dialogue between the patients and their primary care physicians.  Is this an area that pharmacists should prioritize in patient care? If so what options are there for getting more involved in opioid therapy and the risk of OIC?

Article Link

Locasale, Robert. Datto, Catherine. Wilson, Hilary. Yeomans, Karen. Coyne, Karin. The Burden of Opioid-Induced Constipation: Discordance Between Patient and Health Care Provider Reports. J Manag Care Spec Pharm. 2016; 22 (3): 236-245.

Increase in Naloxone Prescriptions Dispensed in US Retail Pharmacies Since 2013

Overdoses from heroin and prescription opioids are a public health crisis in America. One way to reduce the amount of overdoses is to administer naloxone, an opioid antagonist, to those who are likely to witness an opioid overdose. Naloxone was traditionally given out through community programs that would give overdoes educations. Recently there has been a focus on increasing naloxone access through prescribing naloxone in outpatient settings. While there has been data showing the efficacy of naloxone and reducing opioid overdoses in community program settings, this study aimed to analyze the prescription trends of naloxone.

Prescription data was obtained through IMS Health’s National Prescription Audit. The time period observed was from July 2010 and June 2015, and was divided into 3 groups: Evzio, an auto-injector form that was approved in 2014, the 2mg/2mL formulation normally used off label with nasal atomizer, and other formulations. The study found that Naloxone dispensed from retail pharmacis was low and stable from 2010 to 2013, ranging between 241 and 463 prescriptions per quarter. Until June 2015, there was a sharp increase in dispensing, and a 1170% increase since the fourth quarter of 2013. This was mirrored by a 187% increase in the number of naloxone kits given by community programs, and a 160% increase in the number of opioid overdose reversals reported by community programs.

This study shows that prescription of naloxone can aid the efforts of community programs. While community programs distributes the most naloxone, the public health crisis of opioid overdose needs more methods of administering naloxone, and prescriptions for naloxone can help aid this effort. However, there is still more work that needs to be done. This includes examining the barriers patients may face obtaining naloxone, opioid prescribing trends, and any stigma patients may face. Overall, I think that this shows the impact that pharmacist can have in a community pharmacy setting and how we can aid in a public health crisis. By being aware of the impact we can make on an at-risk population, we can try to be conscious of the stigma this population may face and try combat this.

 

 

Reference: Jones CM, Lurie PG, and Compton WM. Increase in Naloxone Prescriptions Dispensed in US Retail Pharmacies Since 2013. Am J Public Health. doi:10.2105/AJPH.2016.303062 (published 18 February 2016).

 

Link: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2016.303062?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&

Development of an opioid reduction protocol in an emergency department

Pain is the leading cause of emergency department (ED) visits.  With the frantic and stressful environment, it doesn’t seem surprising that opiods are commonly prescribed to a patient.  This is more efficient than taking the time to carefully address the patient’s specific needs and concerns and also seems to give the patient instant relief and satisfaction.  As a result, there has been a significant increase in the amount of opioids prescribed in the ED.  This study hopes to test a multimodal pharmacologic approach to analgesic therapy for patients with acute pain which is known as the public health initiative, the “Opioid-Free Shift.”  This multimodal therapy involves using a combination of pharmacologic agents to target multiple receptors that are known to mediate pain transmission.

The research was conducted at the Maimonides Medical Center which has excess visits to their emergency department.  An interprofessional team consisting of physicians, research staff, a clinical pharmacy manager, and nurses worked together to guide the care during the opioid-free shift.  The pain-scale was used as a rationale to determine the type of treatment needed for the patient. For instance, a score of 1-4 yielded a treatment of oral analgesics such as ibuprofen.  Pain scores of 5-10 yielded IV acetaminophen or ketamine along with other IV treatments.  During this opioid-free shift which took place from 7am to 3pm, only 1 out of 17 patients were given an opioid as rescue therapy.  For those patients on the opioid-free treatment, about 83% of the patients were satisfied with the pain relief at 30 minutes, and 86.7% reported satisfaction at 60 minutes. No adverse drug reactions were reported during the study.

This alternative to prescribing opioids seems to prove efficacious, and may be beneficial to potentially decrease the amount of opioid addiction conditions.  My questions posed to colleagues are: What do you think are the benefits or downsides to this approach being potentially practiced more often in hospitals?  How do you think a pharmacist could assist in this treatment?  Would involving a pharmacist specializing in palliative care be beneficial or detrimental?

 Am J Health Syst Pharm. 2015;72(23):2080-2086.

Opioid Overdose Prevention

Here the role of the pharmacist as a key agent in the prevention of opioid overdose is discussed. Through counselling patients on points about safe opioid use and overdose prevention the pharmacists can stop some of these events from occurring at the time of pick up by the patient. These points may include disclaimers about dangerous drug cocktails such as combining benzodiazepines with opioids (as other drugs are found in the systems of most of those who die by opioid overdose. In addition to this the pharmacist can educate both the patients and the providers about naloxone, which in the case of most of the overdoses could prevent death as there is usually a witness to the overdose. Abuse deterrent formulas that prevent the snorting or injecting of these medications can also be considered here.

It should also be noted that pharmacists have a unique opportunity to identify patients as having a high risk factor for opioid overdose. These patients should especially be counselled on such points.

Although a pharmacist may not know everything about the patients that come into their pharmacies it is not uncommon for some information to be disclosed about previous struggles with these drugs since the pharmacist may see the patients much more frequently than the physicians. There are also clear records of drug dispensing from the particular pharmacy that the pharmacist works at that can allow the pharmacist to draw inferences about the patient’s use of these drugs. Furthermore, 49 states have a prescription drug monitoring program that allows the pharmacist to have access to information pertaining to prescriptions filled at multiple pharmacies.

Through educating patients on the risks associated with opioid dependence and overdose, pharmacists can play a part in reducing the number of these preventable injuries and deaths.

Reference

Bratberg J, McLaughlin B, Brewster S. Opioid overdose prevention. J Am Pharm Assoc. 2015; 55(5): 470-77.

J Am Pharm Assoc. 2015; 55(5): 470-477

The Need for More Education on Prescribing Opioids

When hearing the term “opioids” several ideas come to mind: addiction, abuse, under-treatment, overtreatment, severe pain, and suspicion are just a few. Opioids are undoubtedly an extremely successful route of treatment for severe pain and play a huge role in daily pain management cases. However, there is always a discussion of the risks associated with prescribing this medication.

There is often an air of distrust between physician and patient when a patient insists on opioid therapy. Unfortunately, pain cannot be measured, and there needs to be trust when prescribing this drug class. The prescriber will not know if the patient really needs the opioid for pain management or if they have developed a dependence on it. The physician is put in a position where they could under-treat the patient by refusing therapy because of the risk of abuse, or they could over-treat the patient by believing their plea for a medication they were addicted to.

There are several guidelines already in place regarding opioid prescribing, but still, much of it is up to the physician’s discretion. Right now, there is a big push for more prescriber education on the topic. For example, in 2012, the FDA encouraged a single shared Risk Evaluation and Mitigation Strategy (REMS) which required manufacturers of extended release or long acting opioids to fund accredited education on safe opioid prescribing. Currently, this program has not reached its goal number of prescribers. However, I believe with the advancement of this program, physicians will be able to make more educated and thorough decisions when it comes to prescribing opioids.

Managing pain is extremely complex, yet education on the topic is lacking. The ultimate goal would be to maintain a patient-centered approach and treat the patient in a manner in which they are comfortable and compliant with. Perhaps with more education on the topic, the physician and pharmacist can work together to make a confident decision in how to proceed with drug therapy, and hopefully avoid the mistakes that have been occurring concerning opioid therapy.

I personally see this as an opportunity for pharmacists to get more involved in the prescribing process, as they have a stronger background education on the topic. Do you think this could play a role in pharmacists eventually gaining prescribing rights?

 

Read the full article here.

Alford, Daniel P.  Opioid Prescribing for Chronic Pain — Achieving the Right Balance through Education. N Engl J Med. 2016;374:301-3

 

Comparison between Transdermal Buprenorphine and Transdermal Fentanyl for Postoperative Pain Relief after Major Abdominal Surgeries

Opioid medication has been used since its discovery as the necessary treatment for moderate and severe pain, especially post-operative pain.  It is one of the main concerns for patients who undergo such major surgeries such as abdominal surgery.  This study compares the effectiveness of two transdermal medications and their effectiveness on 60 patients.  Half the population was given transdermal fentanyl and half the population was given transdermal buprenorphine.  The results were to be expected.  Around 20% of fentanyl and 16.7% of buprenorphine patients experienced adverse effects, nausea and vomiting being the main adverse effects for most patients.  In general, however, fentanyl was reported to be better at controlling post-operative pain than buprenorphine.  This study also proved that transdermal patches are preferable to oral and IV administration.  This is due to the avoidance of multiple dosing and skin punctures.

I find this article interesting because opioid medications interest me and their varying effectiveness.  Pain is the most common effect patients experience and its management can be a difficult task.  So this study interested me since it compared two different pain medications for post-operative abdominal pain.  I was familiar with fentanyl but not buprenorphine.  Overall, fentanyl still proved to be the most effective.

 

Arshad Z, Prakash R, Gautam S, Kumar S. Comparison between Transdermal Buprenorphine and Transdermal Fentanyl for Postoperative Pain Relief after Major Abdominal Surgeries. Journal of Clinical and Diagnostic Research : JCDR. 2015;9(12):UC01-UC04. doi:10.7860/JCDR/2015/16327.6917.