______________________________________________________ Opioid Safety: Balancing Benefits and Risks
The American Academy of Pain Medicine, which had expressed dismay with the 2016 CDC guideline and how it was misapplied by insurance companies, state governments, and healthcare organizations, indicated general support for the 2022 revision [14]. IDENTIFICATION OF DRUG DIVERSION/ SEEKING BEHAVIORS Urine drug tests can give insight into patients who are misusing opioids. A random sample of urine drug test results from 800 pain patients treated at a Veterans Affairs facility found that 25.2% were negative for the prescribed opioid while 19.5% were positive for an illicit drug/unreported opioid [15]. Nega- tive urine drug test results for the prescribed opioid do not necessarily indicate diversion but may indicate the patient halted his/her use due to side effects, lack of efficacy, or pain remission. The concern arises over the increasingly stringent climate surrounding clinical decision-making regarding aber- rant urine drug test results and that a negative result for the prescribed opioid or a positive urine drug test may serve as the pretense to terminate a patient rather than guide him/ her into addiction treatment or an alternative pain manage- ment program; the CDC states that “clinicians should not dismiss patients from care on the basis of a toxicology test result. Dismissal could have adverse consequences for patient safety, potentially including the patient obtaining opioids from alternative sources and the clinician missing opportunities to facilitate treatment for a substance use disorder” [2]. In addition to aberrant urine screens, there are certain behav- iors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [4; 16; 17]: • Selling medications • Prescription forgery or alteration • Injecting medications meant for oral use • Obtaining medications from nonmedical sources • Resisting medication change despite worsening function or significant negative effects • Loss of control over alcohol use • Using illegal drugs or non-prescribed controlled substances • Recurrent episodes of: ‒ Prescription loss or theft ‒ Obtaining opioids from other providers in violation of a treatment agreement ‒ Unsanctioned dose escalation ‒ Running out of medication and requesting early refills
Behaviors with a lower level of evidence for their association with opioid misuse include [4; 16; 17]: • Aggressive demands for more drug • Asking for specific medications • Stockpiling medications during times when pain is less severe • Using pain medications to treat other symptoms • Reluctance to decrease opioid dosing once stable • In the earlier stages of treatment: ‒ Increasing medication dosing without provider permission ‒ Obtaining prescriptions from sources other than the pain provider ‒ Sharing or borrowing similar medications from friends/family
inter active activity
View the CDC’s video Risk Factors in Opioid Prescribing at https://www.netce.com/learning.php?page=activit ies&courseid=3207. This video addresses the various risk factors likely to increase susceptibility to opioid- associated harms and suggests strategies for mitigating these risks.
FEDERAL AND STATE LAW In response to the rising incidence in prescription opioid misuse, dependence, diversion, and overdose, in 2018 the FDA mandated opioid-specific REMS (i.e., Opioid Analgesic REMS or OA REMS) to reduce the potential negative patient and societal effects of prescribed opioids. Other elements of opioid risk mitigation include the FDA partnering with other governmental agencies, state professional licensing boards, and societies of healthcare professionals to help improve prescriber knowledge of appropriate and safe opioid prescribing and safe home storage and disposal of unused medication [18]. Several regulations and programs at the state level have been enacted in an effort to reduce prescription opioid abuse, diver- sion, and overdose, including [19]: • Physical examination required prior to prescribing • Tamper-resistant prescription forms • Pain clinic regulatory oversight • Prescription limits • Prohibition from obtaining controlled substance prescriptions from multiple providers • Patient identification required before dispensing
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