Opioid Safety Starts with Informed, Mutual Decisions

In March 2016, the Centers for Disease Control and Prevention (CDC) released updated guidelines for prescribing opioids for chronic pain. Giving patients a decision-making role in their pain plan–and providing them with the information they need to arrive at informed mutual decisions–is front and centre in the document.

There is much agreement that the United States is in the midst of an opioid epidemic. In 2012, health care providers wrote 259 million prescriptions for opioid pain medication. Opioid prescription rates per capita increased by 7.3% from 2007 to 2012. Drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015. Opioid addiction is a major force in this epidemic, accounting for 20,101 overdose deaths related to prescription pain relievers during 2015. By contrast, there were 12,990 overdose deaths related to heroin during the same year.

The CDC’s guidelines identify prevention, assessment, and treatment of chronic pain in particular as challenges for health providers and systems. Its guidelines apply to adult patients with chronic pain outside of palliative and end-of-life care, with special attention paid to special populations, such as older adults, pregnant women, and adults with a history of substance abuse.

With no two patients being the same, it is critical that clinicians tailor information for each patient in hospital and on discharge in order to encourage proper use of opioids–and, that the information patients receive empower them to play a role in the decision-making process in their care.

With that in mind, we’ve highlighted some considerations as clinicians provide patients with information about their opioid prescriptions.

Prescription practices for acute pain have implications on long-term opioid usage and possible abuse

According to the sixth recommendation of the CDC’s guidelines:

“Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.”

Clinical research demonstrates an association between opioid use for acute pain and long-term use. Thus when prescribing opioids, it is important to consider opioids among an array of multi-modal options, and to educate patients on the proper use of opioids.

Chris Pasero, MS, RN-BC, FAAN, Pain Management Educator and Clinical Consultant, says:

“When someone has some mild pain, we give them opioids. They have a little more pain, we give them more opioids. They have severe pain, we give more opioids. And, of course, at the top of this pyramid is where we see adverse events including patient deaths. What’s happening nation-wide is a focus on opioid-only treatment plans. This is problematic.”

In hospital and upon discharge, patients need to receive educational information featuring the clinical evidence of the connection between opioid use for acute pain and long-term use. They need to be equipped with the right information to arrive at a mutual decision on whether opioids are right for them.

Effective communication with patients on treatment goals, risks, and realistic benefits of opioid therapy is critical

According to the CDC’s second and third recommendations:

“Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

“Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.”

It can be helpful to be explicit and realistic about the expected benefits of opioids, explaining that while opioids can reduce pain during short-term use, complete relief is unlikely. By being frank about–but sensitive to–the potential for lifelong opioid use disorder and adverse events such as respiratory depression, patients would be empowered to arrive at informed mutual decisions by weighing all of the risks and benefits of the recommended pain treatment.

Understand patient conditions that compound opioid risk and assess patients for risk of opioid-induced respiratory depression

Thomas W. Frederickson MD, FACP, SFHM, MBA, author of the RADEO Guide, points to five strategies to assess patients for risk of respiratory depression when considering opioids as a treatment option:

  1. Screen for sleep apnea
  2. Use a screening tool to identify patients with obstructive sleep apnea
  3. Build multi-modal and opioid sparing strategies for at-risk patient groups
  4. Educate on the risks of interactions with other medication
  5. Empower clinicians with the right tools and policies

Carla Jungquist, PhD, ANP-BC, of the University of Buffalo School of Nursing, agrees:

“I recommend assessing all patients for sleep-disordered breathing and, if found, using continuous monitoring devices to ensure patient safety. I also recommend multi-modal pain management strategies that are opioid sparing. I absolutely believe we can improve patient safety by instituting better monitoring strategies coupled with multi-modal pain management.”

Sharing the result of the risk assessment with the patient could help them form an educated opinion about whether opioids are the right treatment for them.

Involve patients in informed, mutual decisions

According to the CDC’s guidelines:

“Clinicians should involve patients in decisions about whether to start or continue opioid therapy. Given potentially serious risks of long-term opioid therapy, clinicians should ensure that patients are aware of potential benefits of, harms of, and alternatives to opioids before starting or continuing opioid therapy. Clinicians are encouraged to have open and honest discussions with patients to inform mutual decisions about whether to start or continue opioid therapy.”

What information do patients need in order to play a decision-making role in their care?

Travis Rieder, a patient who became hooked on opioids after being struck by a van, offers an answer:

“To responsibly prescribe opioids, physicians must have the relevant information concerning dosing, dependence, weaning schedules and symptom management.”

Travis was opioid-naive when he was prescribed several pain medications at the hospital after his accident. His left foot was shattered and he was in and out of hospitals for more than four weeks, each time receiving opioids for managing his pain. His pain plan included both immediate-release and extended-release oxycodone as well as intravenous morphine, fentanyl and Dilaudid. Upon discharge, he was prescribed more opioids.

To keep the pain under control, Travis’ doctor kept increasing the doses of his pain medications. After some time of long-term use, his original orthopedic surgeon at one point, surprised that Travis was still taking such high doses, suggested he consider getting off the meds. He didn’t offer any strategies to do so, and his plastic surgeon advised an aggressive taper. The symptoms of withdrawal nearly killed Travis–eventually he came through on the other side.

As Travis puts it:

“Physicians, public health officials and even the Centers for Disease Control and Prevention tell us that we are in the midst of an opioid epidemic because of the incredible addictive power of these drugs. Yet when people become addicted to painkillers after suffering a trauma, the best advice they might get from physicians when coping with withdrawal is to go back on the drugs. Can we really do no better than that?”

When we look at areas to do better, one in particular stands out: we need to consider the effects of opioids in pain management across the spectrum of patient needs; not just prescriptions for chronic pain.

Updated guidelines that address postsurgical opioid use–guidelines that apply the same rigour as the chronic pain guidelines–could create a significant positive impact on controlling the opioid epidemic, especially given the link between use for acute pain and long-term usage.

Do you agree?

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