However, the danger from the opioid crisis is ongoing, and HCPs are called on to prescribe judiciously, reserving opioids for pain that does not respond to other treatments. Despite some recent progress on several fronts, the situation in Tennessee remains dire as illustrated by the following statistics: • In 2019, 1,543 Tennesseans died from an opioid-related overdose, an average of more than 4 deaths every day, a 49% increase compared to 1,034 deaths in 2015. 26 • Tennessee had the nation’s third-highest rate of opioid prescriptions (68.5 for every 100 persons) in 2020, which was almost one-and- a-half times higher than the national average of 45.9 prescriptions per 100 persons. 27 • The number of cases of Neonatal Abstinence Syndrome increased slightly from 810 in 2019 to 824 in 2020. 28 Opioids are classified according to their action at mu receptors as full agonists, mixed agonist- antagonists, or antagonists (Table 3). 29-32 Most clinically prescribed opioids are full mu agonists. Buprenorphine has a reduced potential for respiratory depression and acts as an antagonist at the kappa receptor, which is shown to reduce anxiety, depression, and the unpleasantness of opioid withdrawal. 5 Tapentadol and tramadol have dual modes of action as agonists at the mu receptor and SNRIs. 5 Considerations with dual-mechanism opioids include lowering of the seizure threshold in susceptible patients and the risk of serotonin syndrome. 33
Formulations may be extended-release (ER) or immediate-release (IR), and delivery systems for outpatients include oral, transmucosal, and transdermal routes of administration. Combination products contain products such as acetaminophen (ACET) together with an opioid, necessitating careful tracking of daily dose limits so as not to incur risk for liver and GI toxic effects. 34 All transdermal and transmucosal fentanyl and hydromorphone ER products are for use only in opioid-tolerant patients and never for acute or short-term pain. 35 ER/LA opioids are primarily intended to be taken once or twice a day, are not indicated for acute pain, and are for use only in patients who are already tolerant to opioids. 13,35 The primary risk with opioids is respiratory depression leading to death. Some opioids (e.g., methadone) can prolong the QTc interval. ER/LA opioid tablets should be swallowed whole, never crushed, chewed, broken, cut, or dissolved, which may result in rapid release and absorption of a potentially fatal dose. 35,36 Transdermal systems and buccal films should not be cut, torn, or damaged before use nor chewed, swallowed, or patches exposed to heat, which may lead to fatal overdose. Possible opioid side effects include but are not limited to: 5,13 • Lightheadedness
Commonly Prescribed Controlled Substances The 5 drug classes regulated by the CSA are opioids (called “narcotics” by the DEA), sedative- hypnotics, stimulants, hallucinogens, and anabolic steroids. Each class produces its own effects in the body, but all share the commonality that they have the potential for being misused by patients and non-patients. They are also among the most highly sought-after drugs for diversion. 25 Many CS drugs are commonly prescribed for indicated medical conditions. Others, such as cocaine, have very limited medical indications. Non- opioid medications can minimize opioid exposure, and different medications can complement one another; however, each has unique risks and benefits as well as mechanisms of action, 5 and their effects can be synergistic when used in combination. 5 A risk-benefit analysis is always recommended based on the individual patient’s medical, clinical, and biopsychosocial circumstances. 5 Specific categories and medications will be described as required by the State of Tennessee. Opioids As Schedule II medications, opioid prescriptions are not limited by quantity or treatment by the CSA; however, many states and insurance carriers do set limits on quantity, frequency, and duration of prescriptions as well as other facets of treatment and monitoring. Remember that the more restrictive law trumps the less restrictive in regard to prescribing CS. Prescribing for pain has dropped off in recent years after peaking in 2011. 17
• Dizziness • Sedation • Nausea and vomiting • Drowsiness • Mental clouding • Constipation
Table 3. Opioid Analgesic Classifications
Type
Generic Name
Notes/Cautions
Pure agonists
Codeine Dihydrocodeine Fentanyl Hydrocodone Hydromorphone Levorphanol Meperidine* Methadone Morphine Oxycodone Oxymorphone Propoxyphene Partial agonist: Buprenorphine
*Meperidine not recommended for long-term treatment or in patients with renal compromise due to toxicity risks
Agonist-antagonists
May produce withdrawal with physical dependence
Mixed agonist-antagonists: Butorphanol Dezocine
Nalbuphine Pentazocine Naloxone Naltrexone
Pure antagonists
Administered to reverse opioid effects
Other
Tramadol
Dual action mu-agonist and serotonin–norepinephrine reuptake inhibitor
Tapentadol
Dual action mu-agonist and norepinephrine reuptake inhibitor
6
Powered by FlippingBook