The Opioid Epidemic

Educational Objectives

The goal of this program is to improve the responsible prescription of opioids. After hearing and assimilating this program, the clinician will be better able to:

1. Evaluate the extent of the opioid crisis in the
United States.

2. Appropriately prescribe opioid and nonopioid
medications for pain control.

Summary

Background: people dying at increasing rate from prescribed opioids; number of deaths approaching 20,000 per year in United States; deaths from drug poisoning surpassed deaths from motor vehicle-related accidents in North Carolina (NC); goal to decrease deaths while allowing appropriate use of opioids

Children: concerns include unintentional ingestion and overdose, as well as intentional ingestion

Tadros et al (2016): investigated ≈22,000 pediatric visits to emergency department (ED) for poisoning by prescription opioids from 2006 to 2012; intentional use considered recreational use and use for self-harm; percentage of intentional use increased with increasing age

Gaither et al (2016): investigated hospitalizations for opioid poisonings among children and adolescents from 1997 to 2012; found 205% increase in hospitalizations among children aged 1 to 4 yr, no significant change among ages 10 to 14 yr, and 176% increase between ages 15 and 19 yr; found 300% increase in accidental deaths and 160% increase in deaths related to suicide or self-harm among adolescents aged 15 to 19 yr; 16 cases of overdose by intention or self-harm among children aged <10 yr; found 160% increase in poisonings by heroin and 950% increase in poisonings from methadone

Methadone: potentially dangerous because of highly variable bioavailability; many factors affect cytochrome P450 system; half-life varies, between 8 and 59 hr; chronic use causes autoinduction of enzymes; half-life longer in opioid-naïve individuals; although methadone long-acting, duration of analgesic effect only 4 to 8 hr; respiratory depression peaks later than analgesic effect, so individuals naïve to methadone may take multiple doses and may die within 4 to 6 days of initiation

Statistics: 2500 adolescents aged 12 to 17 yr per day misuse opioid for first time in United States; sources of drugs (Daniulaityte et al, 2014) — found that 46.7% of young adults used leftover opioids from own prescriptions; significant number used opioids medically before nonmedical use; individuals who use opioids nonmedically often progress to heroin; 87.7% received opioids from friends for free, 44% received from relatives, and 80.2% bought them

Availability: opioids easy to obtain; website (streetrx.com) even offers guidance on regional prices for numerous drugs

McDonald et al (2017): surveyed 681 adults in households with children to determine safety of storage for opioid medications; safe storage defined as locked or latched; found 32.9% stored safely in households with children aged <6 yr, 11.7% with children aged 7 to 17 yr, and 29% with both age groups present

Additional considerations: children of friends may obtain improperly stored drugs; some individuals steal drugs from medicine cabinets in houses for sale; >500 million opioid pills dispensed in 2016 in NC

Fortuna et al (2010): investigated prescription of controlled medications to adolescents (aged 15 to 19 yr) and young adults (aged 20 to 29 yr) during ambulatory care; 21.5% of adolescents and 33.4% of young adults with back pain received opioids; 19% of patients receiving opioids had back or musculoskeletal pain, and 11% had primarily psychiatric diagnoses or insomnia

Root causes: emphasis on considering pain as fifth vital sign; extended-release oxycodone (Oxycontin) approved by US Food and Drug Administration in 1996; promoted as safe method for control of pain with minimal likelihood of addiction if used for conditions legitimately causing pain; Phillips (2000) stated that “excuses for inadequate pain control appear to have run their course and will no longer be accepted because poor pain control is unethical, clinically unsound, and economically wasteful”; National Pharmaceutical Council stated, “In general, patients in pain do not become addicted to opioids. Although the actual risk of addiction is unknown, it is thought to be quite low,” in guide for assessment and treatment of pain issued in 2001; further stated that fears of addiction among prescribers sometimes reflect lack of understanding of risk for addiction with therapeutic use of drugs; Oxycontin aggressively marketed

Carfentanil: used to sedate elephants; ≈10,000 times more potent than morphine (heroin about twice as potent as morphine); fentanyl and carfentanil sometimes added to heroin

Statistics: in NC, 3 people die daily because of overdose of opioid; 3 hospitalizations and 4 visits to ED occur for every overdose in state; almost 350,000 residents of NC admitted to misuse of prescription drugs in 2014; almost 4.3 million people used opioids for nonmedical reasons in United States in 2014; highest proportion in young adults aged 18 to 25 yr; mortality in United States increased in 2015 because of overdoses and suicides; 40,000 suicides in United States annually (double number of opioid-related deaths)

Solutions: necessary to educate selves, other prescribers and providers, nurses, and parents; consider nonopioid options for control of pain; study found 52% of children with severe sprain or fracture in ED had good analgesia with acetaminophen; addition of codeine did not improve pain scores but increased side effects; precautions — prescribe opioids responsibly; store opioids safely; dispose of opioids appropriately

Readings

Daniulaityte R et al: Sources of pharmaceutical opioids for non-medical use among young adults. J Psychoactive Drugs 2014 Jul-Aug;46(3):198-207; Fortuna RJ et al: Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics 2010 Dec;126(6):1108-16; Gaither JR et al: National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012. JAMA Pediatr 2016 Dec 01;170(12):1195-201; McDonald EM et al: Safe storage of opioid pain relievers among adults living in households with children. Pediatrics 2017 Mar;139(3); National Pharmaceutical Council: Pain: current understanding of assessment, management, and treatments. 2001. www.npcnow.org/system/files/research/download/Pain-Current-Understanding-of-Assessment-Management-and-Treatments.pdf. Accessed October 3, 2017; Phillips DM: JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA 2000 Jul 26;284(4):428-9; Tadros A et al: Emergency department visits by pediatric patients for poisoning by prescription opioids. Am J Drug Alcohol Abuse 2016 Sep;42(5):550-5.

Disclosures

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

Acknowledgements

Dr. Chidgey was recorded at the 10th Annual UNC-Duke-Wake Forest Pediatric Anesthesiology Conference: Best Practices in Pediatric Anesthesia Care, held September 23, 2017, in Chapel Hill, NC, and presented by the Schools of Medicine of the University of North Carolina at Chapel Hill, Duke University, and Wake Forest University, Departments of Anesthesiology and Pediatrics. For information about upcoming CME opportunities from the University of North Carolina School of Medicine, please visit med.unc.edu/cpd. For information about upcoming CME opportunities from Duke University School of Medicine, please visit medicine.duke.edu/education-and-training/continuing-medical-education. For information about upcoming CME opportunities from Wake Forest School of Medicine, please visit wakehealth.edu/office-of-continuing-education. 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:

AN594701

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.