The Abuse Epidemic in the United States: Opioids and Benzodiazepines

Educational Objectives

The goal of this program is to improve management of patients on opioid therapy. After hearing and assimilating this program, the clinician will be better able to:

1. List factors that contribute to opioid abuse and misuse.

2. Review data about opioid use for chronic pain and cancer pain management.

3. Minimize risks of opioid use by using appropriate screening tools and discontinuing long-term use.

Summary

Response to opioid crisis: 2016 — Centers for Disease Control and Prevention (CDC) released new guidelines about prescribing opioids in noncancer, nonpalliative care settings; 2017 — President Trump declared opioid emergency; no changes in policy made; 2018 — Pennsylvania declared state of emergency (after 8 other states did so); led to removal of regulatory holdups and increase in state funding to address opioid use disorder; Food and Drug Administration (FDA) commissioned National Institutes of Health Academies of Sciences, Engineering, and Medicine (NASEM) to characterize epidemic and recommend actions for FDA and other parties; report focused on characterizing evolving role that opioids should play in pain management, describing epidemiology of prescription opioid abuse and misuse, and detailing recommended pharmacologic approaches

Deaths from drug overdose in United States: 37,000 deaths from opioid overdose in “past calendar year” (2017) and 64,000 total drug overdose deaths; these involve heroin, synthetic opioids (eg, fentanyl, oxycodone, hydromorphone), cocaine, methamphetamine, and methadone; number of deaths increasing; more common in men than in women; benzodiazepines — number of fatal overdoses without opioids also in system stable; concomitant use of benzodiazepines and opioids significantly affects respiratory drive and increases risk for overdose

Causes of opioid abuse and misuse: intertwining of distribution and use of prescription opioids with increased use of illicit opioids; most users of heroin report that opioid use disorder began with prescription opioids; oxycodone (OxyContin) — in 2000, most widely abused opioid; sales grew to $1.1 billion; Purdue Pharma spent >$200 million in marketing in 1 yr and provided coupons for free 30-day supply; by 2001, 34,000 coupons redeemed; Medicare coverage — Medicare does not cover many alternative pain treatments; coverage of alternative pain treatments and therapies could reduce demand for opioids to address chronic pain

Concerns of primary care providers about prescribing opioids: misuse of opioid medications; stressful nature of managing patients with chronic pain; patient addiction; insufficient training in prescribing opioids; most believe there are appropriate times to use opioid pain medications

Evolving role of opioids in pain management: CDC guidelines exclude some patients (eg, those in active cancer therapy); however, cancer survivors with chronic pain who have completed cancer treatment, are in clinical remission, or under cancer surveillance are within scope of guidelines

Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) study: patients with moderate to severe chronic back pain or hip or knee osteoarthritis randomized to opioid therapy or nonopioid therapy (eg, acetaminophen, nonsteroidal anti-inflammatory drugs, tramadol, amitriptyline, gabapentin) for 12 mo; pain-related function as assessed by Brief Pain Inventory (BPI) was primary outcome; findings — after 12 mo, 69 participants in opioid group and 70 participants in nonopioid group had functional response to treatment (ie, >30% improvement on BPI); individuals in opioid group did not feel better or report improved health-related quality of life compared to those in nonopioid group; opioid group had significantly more medication-related symptoms than nonopioid group; important to discuss treatment goals with patient, as well as risk for opioid use disorder and overdose; conclusion — overall, opioids did not demonstrate any advantage in this population over nonopioid medications that could potentially outweigh their greater risk for harms

Management of cancer pain: increasing evidence suggests that survival linked to symptom control; according to National Comprehensive Cancer Network guidelines, goals of pain management include comfort, function, and safety; guidelines recommend opioids for cancer pain; proper assessment critical; adjuvant therapy helpful; avoid combination products (eg, combination of acetaminophen and oxycodone [Endocet, Percocet, Primlev]); for continuous cancer pain; data strongest for long-acting opioid therapy and use of medications as needed (decreases daily morphine milligram equivalents [MME]); exceptions include incident pain and end-dose failure

American Psychiatric Associations guidelines for generalized anxiety disorder and panic disorder: because selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, and benzodiazepines appear roughly comparable in efficacy for panic disorder, selecting medication for particular patient mainly involves consideration of side effects, cost, pharmacologic properties, drug interactions, treatment history, and comorbidities

Opioid use for >90 days: after 90 days of continuous use, opioid treatment significantly more likely to be lifelong (can result in opioid use disorder, hypogonadism, erectile dysfunction, complications of sleep apnea); studies show that patients who continue opioids for >90 days tend to be higher-risk patients

Pharmacologic approaches to minimize risk: opioid doses >100 MME/day significantly increase risk for overdose; re-evaluate patients (or consult pain management specialist) if patients taking >90 MME/day; long-acting or extended-release formulations increase risk for overdose without significant benefit (except in cancer patients); address use of opioids plus benzodiazepines, and in patients with sleep-disordered breathing, depression, substance use disorder, poor coping strategies, and lack of social support (patients at risk for addiction and overdose)

Screening tools: helpful for assessing baseline risk and eliciting further information from patients; Opioid Risk Tool, Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP-R), and Brief Risk Questionnaire recommended by CDC; screen before initiating therapy and annually thereafter; urine drug screening — CDC recommends performing before starting opioid therapy (consider performing annually); positive result for, eg, morphine or heroin may be followed with more quantitative testing; must be performed as point-of-care test; urine dipsticks associated with high false-positive rates; urine drug screening may be combined with behavioral monitoring; probability of substance use disorder higher with greater number of behavioral red flags (eg, reports of lost or stolen prescriptions, excess consumption, presenting without appointments, frequent phone calls, aggressive behavior with office staff)

Recommendations: communicate expectations and set goals with patients; check interconnected prescription drug monitoring programs (call other physicians if any concerns); increase access to opioid use disorder treatment programs

Discontinuing long-term (>90 days) opioid use: set limits with patient; written treatment plan helpful; consider alternative treatments (eg, cannabis, acupuncture, physical therapy); tapering 10% of total daily dose per week well tolerated; aggressively treat withdrawal symptoms (with, eg, oral or transdermal clonidine or gabapentin); do not give benzodiazepines

Naloxone (eg, Evzio, Narcan): recommended that patients taking opioid doses ≥50 MME/day be prescribed naloxone (also consider for high-risk patients on lower doses); instructions — give single spray intranasally in one nostril; call 911; give additional doses using new nasal spray with each dose if patient does not respond or responds and then relapses into respiratory depression (additional doses may be given every 2-3 min until emergency medical assistance arrives); educate patients and others in home about use

Conclusion: use screening tools and document objective measures; buprenorphine-naloxone (Suboxone), naloxone, and naltrexone extended-release injectable suspension (Vivitrol) helpful for overdose; duloxetine may be effective for neuropathic pain, but more effective for comorbid anxiety and depression

Readings

Krebs EE et al: Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018 Mar 6;319(9):872-882; Liebschutz JM et al: Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized clinical trial. JAMA Intern Med. 2017 Sep 1;177(9):1265-1272; Munzing T: Physician guide to appropriate opioid prescribing for noncancer pain. Perm J. 2017;21; Pinkerton R, Hardy JR: Opioid addiction and misuse in adult and adolescent patients with cancer. Intern Med J. 2017 Jun;47(6):632-636; Sun EC et al: Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ. 2017 Mar 14;356:j760; Wheeler E et al: Centers for Disease Control and Prevention (CDC). Opioid overdose prevention programs providing naloxone to laypersons — United States, 2014. MMWR Morb Mortal Wkly Rep. 2015 Jun 19;64(23):631-5.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Worster was recorded in Rehoboth Beach, DE, at the 41st Annual Eastern Shore Medical Symposium, presented June 18-22, 2018, by Sidney Kimmel Medical College at Thomas Jefferson University and University of Delaware. Visit cme.jefferson.edu for information about upcoming courses. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP671301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.