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ODs are able to recognize drug abuse and offer resources to help patients
While most ODs are not permitted to prescribe opioids for more than a few days’ duration, they are positioned well as frontline healthcare providers to recognize abuse and provide resources. The CDC’s prescribing guidelines are a good resource.
In the wake of the COVID-19 pandemic, ODs’ thought processes have turned foremost to the concept of contagion and how to prevent the spreading of germs. I won’t say, however, that I was disappointed to have the opportunity to lecture (albeit virtually) on a completely separate topic a few weeks ago. It was a sobering topic that has killed more than half a million Americans over the last 20 years—the opioid crisis.1
By the numbers
As of 2016, the number of drug overdose deaths in the U.S. had increased five-fold from 1999, and about two-thirds of these deaths involved an opioid. From 1999 to 2010, the amount of opioids sold legally in the U.S. increased four-fold, while the amount of pain reported by Americans remained relatively flat.1
Interestingly, opioid related deaths also increased four-fold during that time period. So, are these people all heroin addicts? Well, three-fourths of those who are report using a prescription opioid prior to using heroin. This is a clear example of the concept of the gateway drug.1
Moving beyond 2010, the period of time between 2010 and 2016 saw a five-fold increase in heroin-related deaths. The number of synthetic opioid related deaths was approximately 9580 in the U.S. in 2015; that number jumped to 19,413 in 2016. Washington, DC, itself, experienced a 108.6 percent increase in overdose deaths during this time frame.1
Also during this time frame, fentanyl, a potent narcotic indicated for the treatment of severe pain, started showing up in greater numbers on the streets, sometimes being added to heroin (with or without the user’s knowledge).1
As for legally prescribed opioids, in 2013 almost 250 million prescriptions were written in the U.S. Alabama had the highest rate, and Hawaii had the lowest. Those numbers have declined a bit since then, with 2012 seeing 81.3 opioid prescriptions dispensed for every 100 persons in the U.S., and 2016 seeing 66.5. However, in 2016 one-quarter of all counties in the U.S. had enough opioid prescriptions written for every resident to have his own bottle.1
So, who is more likely to die from an overdose? Data from 1999 to 2014 showed the highest rates among those aged 25 to 54 with higher rates among males. Non-Hispanic whites were also more likely to die from an overdose than non-Hispanic blacks or Hispanics. As of 2015, the southern U.S. had the highest overdose death rate (from a natural or synthetic opioid) with 4.4 for every 100,000 persons. Specifically for synthetic opioid overdose death rates, 2015 saw the Northeast having the highest rate— 5.6 for every 100,000 persons.1
Epidemiology is important for two reasons. The first reason is simply that it needs to be known, and the second reason is to show the clear need for guidance with the prescribing of opioids.
Of course, the U.S. has its controlled substance drug schedules.2
Schedule I controlled substances are those for which the federal government recognizes no accepted medicinal value. Heroin and lysergic acid diethylamide (LSD) are both Schedule I controlled substances.
Schedule II controlled substances have accepted medicinal value but are recognized as having a high potential for abuse. Cocaine is actually Schedule II and is still used at times as a local anesthetic for some surgeries (albeit with a significant degree of paperwork).
Oxycodone and hydrocodone exist in this schedule, as well. In fact, when hydrocodone was moved to this schedule from Schedule III several years ago, many state legislatures passed so-called “hydrocodone fix” legislation so that ODs forbidden by law from prescribing Schedule II medications could still prescribe hydrocodone.
Schedule III controlled substances are recognized as having a lower potential for abuse but still carry a significant risk for physical or psychological dependence. A common example of such is codeine (so long as it is in a quantity of not more than 90 mg per dosage unit).
Schedule IV controlled substances are recognized as having a lower potential for abuse relative to Schedule III and include several anti-anxiety and sedative medications.
Finally, Schedule V controlled substances are recognized as having low potential for abuse. This schedule includes medications with limited quantities of narcotics, such as cough suppressants with no more than 200 mg of codeine per 100 ml or per 100 g.
The U.S. Drug Enforcement Administration (DEA) drug schedules provide a good framework for prescribers. The Centers for Disease Control and Prevention (CDC) has also published prescribing guidelines which cover such topics as how progress is assessed, how and when discontinuation should be considered, and how to choose the proper medication.1
Out of these guidelines come 12 recommendations. They are:
1. Opioids should not be seen as first-line therapy, and benefits must outweigh risks for an opioid to be deemed necessary. If an opioid is deemed necessary, combine with a non-opioid medication as appropriate. A common reason an OD would prescribe an opioid would be a corneal abrasion causing severe acute pain. This first recommendation could play out in the clinician’s flowchart of thought process during the examination and does not mean that a lengthy trial period of non-narcotic pain management is always required prior to initiation of opioid therapy.
2. Goals should be established prior to starting opioid therapy. These goals should be realistic and used to assess treatment efficacy and patient function.
3. Risks and benefits should be discussed prior to starting opioid therapy. The benefits should be realistic.
4. Immediate-release opioids should be used when starting therapy (as opposed to starting with “extended-release” or “long-acting” opioid formulations.
5. The clinician should prescribe what she deems is the lowest effective dose. The clinician should strive to avoid increasing a dosage to 90 mme (morphine milligram equivalents) per day or carefully titrate to that level if necessary.
6. Short-term therapy should be prescribed for acute pain (versus chronic pain). A duration of 3 days or less is often sufficient for acute pain, with more than one week’s duration being rarely needed—again, as opposed to chronic pain.
7 The benefits and harms of opioid therapy should be frequently reevaluated. There should be a goal of tapering or discontinuing opioid therapy if feasible.
8. Strategies should be used to mitigate risk. These may include offering naloxone (Narcan, Adapt Pharma) when a higher potential for abuse, such as a history of overdose, increased dosage, or concurrent benzodiazepine use, is present.
9. The Prescription Drug Monitoring Program (PDMP) data should be reviewed by the clinician. The PDMP is a statewide electronic database that tracks all prescriptions for controlled substances. ODs who have a DEA license should be in this database. This database can be used to determine if a patient is receiving dosages that may increase the risk for abuse.
10. Urine drug testing is recommended prior to starting opioid therapy for chronic pain and should be considered at least annually. It should be noted here that a corneal abrasion is considered acute, not chronic, pain.
11. Avoid concurrent opioid and benzodiazepine use whenever possible. Benzodiazepine is a sedative often used for anxiety or insomnia, such as Xanax (alprazolam, Pfizer) or Valium (diazepam, Roche).
12. Offer to treat opioid use disorder. This typically involves medication-based therapy combined with behavioral therapy.
Reading through these guidelines may seem like a bit of a stretch for ODs because many are not permitted to prescribe an opioid for more than a couple of days’ duration and are not involved in treating chronic pain with opioids. However, ODs are well positioned as frontline healthcare providers to recognize abuse and have resources available to which they can refer patients if necessary.
Understanding opioid use and abuse is key to ODs playing a role in fighting the opioid crisis.
1. Centers for Disease Control and Prevention. Opioid Overdose. Available at: www.cdc.gov/drugoverdose. Accessed 6/24/20.
2. Drug Enforcement Administration. Controlled Substance Schedules. Available at: www.deadiversion.usdoj.gov/ schedules/#define. Accessed 6/24/20.