Opioid Safety, Respiratory Compromise

Prince and the Opioid Epidemic: 5 Ways for Addressing this National Crisis

Prince was not the first, nor unfortunately the last, person to die due to an opioid-related event. According to the medical examiner, Prince died from a self-administered fentanyl overdose.

While Prince may have become the poster child for the opioid epidemic and a call for restrictions on the use of opioids, it must not be forgotten that opioids play a vital role in the management of pain, such as during surgery or to relieve chronic pain.

Prince - source: https://en.wikipedia.org/wiki/Prince_(musician)

Prince – source: https://en.wikipedia.org/wiki/Prince_(musician)

With the needs of chronic pain sufferers in mind, the Centers for Disease Control and Prevention (CDC) recently issued the “Guideline for Prescribing Opioids for Chronic Pain”. In that Guideline, the CDC describes the need for addressing this issue:

Chronic pain has been variably defined but is defined within this guideline as pain that typically lasts >3 months or past the time of normal tissue healing. Chronic pain can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or an unknown cause. Estimates of the prevalence of chronic pain vary, but it is clear that the number of persons experiencing chronic pain in the United States is substantial. The 1999–2002 National Health and Nutrition Examination Survey estimated that 14.6% of adults have current widespread or localized pain lasting at least 3 months.

To ensure the appropriate prescribing of opioids, below are 5 of these key resources:

#1 – Ensure Prescribing an Opioid is Appropriate

This Checklist for Prescribing Opioids for Chronic Pain from the CDC provides considerations for prescribing long-term opioid therapy and for renewing and reassessing its continued use.

Moreover, whenever an opioid is prescribed, ensure that the dosage is appropriate:

Higher dosages of opioids are associated with higher risk of overdose and death—even relatively low dosages (20-50 morphine milligram equivalents (MME) per day) increase risk. Higher dosages haven’t been shown to reduce pain over the long term.

To listen to a discussion from CDC’s Clinician Outreach and Communication Activity (COCA) on how to assess the benefits and harms of opioid therapy, please click here.

#2 – Consider the Use of Non-Opioid Treatment

This Nonopioid Treatments Fact sheet discusses the use of non-opioid treatments, saying:

Patients with pain should receive treatment that provides the greatest benefit. Opioids are not the first-line therapy for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Evidence suggests that nonopioid treatments, including nonopioid medications and nonpharmacological therapies can provide relief to those suffering from chronic pain, and are safer.

To listen to a discussion by health experts on the use of non-opioid treatment, please click here.

#3 – Recognize that Each Patient Reacts Differently to Opioid Dosages

Prescribers should recognize that each patient reacts differently to opioid dosages. In a recent podcast with Richard Kenney, MSM, RRT, NPS, ACCS, RCP (Director, Respiratory Care Services, White Memorial Medical Center), the differing effects of opioids with different patients was discussed:

We know that patients react differently to medications. Some react lightly and some have some pretty severe reactions to it. Opioids at certain dosages can lead to respiratory depression, as we know. If too depressed, the risk of respiratory failure could occur and jeopardize the patient’s health. If it goes unnoticed by those monitoring that patient, for example, the patient may appear to be OK at a simple glance, but when the respiratory rate drops, we’re now faced with a compromised patient. So, it’s important that we pay particular attention to those patients receiving opioids …

I have a family member who is very sensitive to medications and what would be a standard dosage to a normal patient, this family member overly reacts to it. And, then on the other side, I have another family member who could take the dose that would knock a charging rhino down and it doesn’t affect them at all. So, it’s really important that we have that additional tool – end tidal CO2 monitoring – just to have that extra safety net for the patient.

In Sentinel Event Alert #49 “Safe use of opioids in hospitals”, The Joint Commission sets forth the characteristics and clinical conditions of patients most at risk of oversedation and respiratory depression:

Characteristics and clinical conditions of patients most at risk of oversedation and respiratory depression

Characteristics and clinical conditions of patients most at risk of oversedation and respiratory depression

#4 – Reduce the Long-Term Use of Opioids

This Pocket Guide: Tapering Opioids for Chronic Pain sets forth recommendations for tapering the use of opioids:

Follow up regularly with patients to determine whether opioids are meeting treatment goals and whether opioids can be reduced to lower dosage or discontinued.

On COCA, there is a discussion on opioid dosing and titration.

#5 – Ensure the Highest Risk Patients are Monitored

In “2016 Top 10 Patient Safety Concerns for Healthcare Organizations”, ECRI Institute says that inadequate monitoring for respiratory depression has the greatest likelihood of preventable harm, receiving the highest risk map score of 80:

Opioid Monitoring Risk Map

Opioid Monitoring Risk Map

Although ECRI is referring to in-hospital use of opioids, arguably, the notion that patients outside of the hospital setting should be monitored is no different.

To hear a discussion with ECRI’s Patient Safety Analyst, Stephanie Uses, PharmD, MJ, JD, please click here.

For other resources on the prescribing of opioids by the CDC, please visit CDC’s resource page.

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