FORT LAUDERDALE, FL—Opioids are not always appropriate for treating pain, and if they have to be prescribed, they must be used cautiously and at the lowest effective dosage, advises Lynn R. Webster, MD.
Misuse and abuse of pharmaceuticals, including opioids, rank high among the nation’s public health concerns. Emergency department visits involving these drugs increased from 627,000 in 2004 to nearly 1,430,000 in 2011, according to the latest data from the Substance Abuse and Mental Health Services Administration. Narcotic pain relievers were among the most commonly misused or abused drug (134.8 emergency department visits per 100,000 population).
Although a majority of overdose deaths due to opioids occur in people who obtain them illegally, “there’s a subset that physicians are responsible for,” said Dr. Webster, President of the American Academy of Pain Medicine (AAPM), at the organization’s 2013 Annual Meeting.
Lynn R. Webster, MD
For the past eight years, since Utah’s medical examiner was quoted as saying that there was an epidemic of overdose deaths from prescription drugs, Dr. Webster has been on a mission to establish easy-to-follow, evidence-based principles for safe opioid prescribing in outpatient settings.
Various guidelines on safe opioid prescribing are currently available, “and they are all useful and helpful, but not specific enough to have an immediate impact,” said Dr. Webster, who is also the Medical Director of CRI Lifetree in Salt Lake City. “They address grander, larger problems. But these eight principles are specifically targeted to prevent deaths.”
For easy recall, the principles are summed up in the acronym RELIABLE (Respiratory, Experience, Long term, Initiating methadone, Apnea, Benzodiazepines, Look for comorbidities, and Exercise caution with switching). They are now part of the AAPM’s Safe Opioid Prescribing Initiative, as follows:
• Respiratory: If a patient who is on long-term opioids develops a respiratory condition (eg, asthma, pneumonia, or influenza), reduce the opioid dose by 20% to 30%.
• Experience: Assess the patient before prescribing opioids. Find out what the biologic, social, and psychiatric risk factors are.
• Long term: Extended-release opioids should not be used for acute pain. “And that’s the bottom line,” said Dr. Webster.
• Initiating methadone: “Never start anybody on more than 15 mg a day,” Dr. Webster advised, adding that the wrong starting dose for methadone can be lethal. “There are reported deaths of people on 30 mg a day,” he said.
• Apnea: Screen for obstructive and central sleep apnea. Screen for hypoxemia. “[For] patients who are on 150-mg morphine-equivalent, people who are very overweight, and people who are infirm and elderly, we need to make sure that opioids are safe for them, and we need to do sleep studies,” said Dr. Webster.
• Benzodiazepines: They “should be avoided if at all possible when you are prescribing opioids,” because when taken with benzodiazepines, the toxicity of opioids is significantly enhanced, noted Dr. Webster. “If a benzodiazepine is used, reduce the dose of opioids. And look for an alternative [to benzodiazepines] if you have to prescribe an opioid,” he said.
• Look for comorbidities: Find out if patients have a history of bipolar disorder, posttraumatic stress disorder, depression, stress, “and particularly general anxiety disorder,” Dr. Webster commented. “Patients will often misuse the medications for their mental health disorder instead of their pain.
• Exercise caution with rotation: “Conversion tables and equal analgesic tables should not be used to determine the starting dose of opioids,” said Dr. Webster. “You have to assume that everybody is opioid naïve. Start on a low dose, and titrate slowly to a level that you think is the maximum dose that you can safely prescribe.
“Physicians can have an impact in reducing the number of overdose deaths, but it’s going to require a little bit of effort to learn these eight principles, and if we all do this, I think we’ll see a dramatic reduction in overdose deaths,” Dr. Webster said.
The principles are likely to be published soon, he noted, and they will be available on the AAPM’s website (http://www.painmed.org) in the near future.
—Naseem S. Miller
IMNG Medical News