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Prescription opioids and the opiate epidemic
- 1. Pain Management and the Opiate Epidemic Savanna Altman Health 4000 Spring 2017
- 2. What are opioids? Substances derived from opium. Opium is made from dried and chemically processed sap from poppy seed pods. Opioids are most often used medically for pain treatment because of their action on nociceptors.
- 3. Mechanism of action ● Location of opioid receptors: ○ Nociceptive (pain) circuits ○ Reward regions of the brain ○ Emotion regions of the brain ● Types opioid receptors: ○ Mu* - Most common target of opioid pain medication ○ Delta ○ Kappa ○ Opioid receptor like-1* not sensitive to naloxone ● Signaling pathways: ○ G-protein (pertussis toxin-sensitive) subunits dissociate and cause hyperpolarization and inhibit neurotransmitter release.
- 4. Results - why we use opioids Analgesia - hyperpolarization and inhibition of neurotransmitters prevents pain signal transduction to the spinal cord and thus reception and perception by the brain. Euphoria - inhibition of the neurotransmitter GABA causes an increase in dopamine release. Codeine is used as a cough suppressor.
- 5. Adverse effects ● Respiratory depression* ● Constipation ● Urinary retention ● Drowsiness ● Decreased blood pressure and heart rate ● Sexual dysfunction ● Confusion ● Nausea and vomiting ● Some suppression of immune function* ● Hyperalgesia* increase in pain sensitivity ● Endocrine disruption
- 6. Tolerance/Dependence/Addiction? ● Tolerance - requiring an increasing dose to achieve pain relief ○ Mechanism? ● Prescription drugs are misused and abused more often than any other drug, except marijuana and alcohol. ● Risk factors for the development of dependence ○ History of opioid abuse, Genetics (mu receptor genes), age, depression, psychotropic medication use ● Dopamine receptors decrease in addicted brains. ● One study showed 25% of out-patients struggled with addiction to their prescribed opioid. ● NIDA states that “an addiction disorder occurs in about 5% of people who take these pain relievers as directed over the period of a year”.
- 7. The DSM-5 identifies opioid use disorder as continued opioid use despite adverse consequences. The disorder is characterized by at least two of the following criteria occurring in a 12-month period ✓ Taking an increased dose or prolonged course of opioids. ✓ Experiencing a persistent desire for opioids and unsuccessfully decreasing or controlling opioid use. ✓ Spending extensive time obtaining, using or recovering from use of opioids. ✓ Craving or having a strong desire to use opioids. ✓ Using opioids in a way that interferes with major life obligations. ✓ Continuing to use opioids despite negative social and interpersonal consequences caused by opioid use. ✓ Avoiding social, occupational or recreational activities because of opioid use. ✓ Using opioids in physically hazardous situations. ✓ Continuing opioid use despite physical or psychological problems resulting from or exacerbated by opioid use. ✓ Developing tolerance. ✓ Developing opioid withdrawal syndrome or taking opioids to avoid withdrawal.
- 8. Prescription opioids ● Opiates - natural ○ Morphine, codeine, heroin, opium. ● Opioids - synthetic ○ Methadone, OxyContin, hydrocodone, fentanyl. ● Opioid prescriptions quadrupled between 1999 and 2014 ● An estimated 1 out of 5 patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings. ● Highest prescribing rates: ○ pain medicine (49%), surgery (37%), and physical medicine/rehabilitation (36%). ● Most common drugs involved in overdose deaths: ○ Methadone ○ Oxycodone (such as OxyContin®) ○ Hydrocodone (such as Vicodin®)
- 9. Pain epidemiology More than 100 million Americans experience chronic pain (20-30%) more than diabetes and heart disease. The cost of health care due to pain ranges from $560 billion to $635 billion (in 2010 dollars) in the United States, which combines the medical costs of pain care and the economic costs related to disability days and lost wages and productivity.
- 10. Opioid use Epidemiology ● The demographic of prescription opioid abusers has shifted: ○ older (mean age at first opioid use, 22.9 years), Most common overdosed: 25-54 ○ less minority ○ more rural/suburban ○ fewer gender differences ○ Predominately white ● Youth: ○ Pain relievers are the most common drugs leading to youth ER visits. ○ Last year an average of 5,784 adolescents used Rx pain relievers for the first time EACH DAY. ● Older adults: ○ Experience more problems with smaller amounts ○ Are at higher risk for medication misuse
- 11. Epidemiology (continued) As opioid prescriptions quadrupled in the last decade, so did opioid overdose deaths. From 2013 to 2014, the overdose death rates related to opioids rose 14 percent, reaching 9.0 per 100,000-people. In 2010, there were 13,652 unintentional deaths from opioid pain relievers (82.8 percent of the 16,490 unintentional deaths from all prescription drugs).
- 14. What about tapering? Tapering should be included in treatment plans made at the start of treatment. Regimen depends on what is being treated and the patient. 10% per week is considered a reasonable starting point. It’s not recommended to reverse a taper, but slowing and even pausing a taper is an acceptable technique. Guidelines for tapering opioids include determining if the patient is experiencing any negative consequences of their drug use… These clues are details that the patient must disclose to a physician, and therefore are easily disguised.
- 15. Illicit opioids Frequent prescription opioid users and those diagnosed with dependence or abuse of prescription opioids are more likely to switch to heroin. Dependence on or abuse of prescription opioids has been associated with a 40-fold increased risk of dependence on or abuse of heroin. Data from the National Survey on Drug Use and Health, less than 4 percent of people who had abused prescription opioids started using heroin within 5 years Those who transition to heroin use tend to be frequent users of multiple substances (polydrug users) Accessibility - In a recent survey of people in treatment for opioid addiction, almost all—94 percent—said they chose to use heroin because prescription opioids were "far more expensive and harder to obtain" Mexican heroin production increased from an estimated 8 metric tons in 2005 to 50 metric tons in 2009—more than a six-fold increase in just 4 years. 2014 NSDUH report: 12.7% of new illicit drug users began with prescription pain relievers.
- 17. Solutions ● CDC published its “Guideline for Prescribing Opioids for Chronic Pain” in March 2016: ○ 1. Use non-pharmacological and non-opioid pharmacologic therapy. ○ 2. Establish treatment goals for long-term opioid therapy. ○ 3. Prior to starting and periodically during treatment, clinicians should discuss risks and benefits of opioid therapy. ○ 4. Prescribe immediate-release opioids whenever possible, especially when starting opioid therapy. ○ 5. Start opioid therapy at the lowest effective dose and gradually increase the dose with caution if needed. ○ 6. For acute pain, prescribe the lowest effective dose of immediate-release opioids for only the expected duration of severe pain (three to seven days). ■ Acute pain - experienced 0-6 weeks from injury or surgery. ○ 7. One should frequently monitor the benefits and harms of opioid therapy. ○ 8. Evaluate risk factors for opioid-related harm and incorporate strategies to decrease these risks ○ 9. Review state prescription drug monitoring program (PDMP) data. ○ 10. Use urine drug testing prior to starting and at least annually when prescribing opioids for chronic pain. ○ 11. Avoid concurrent prescribing of opioids and benzodiazepines ○ 12. Offer evidence-based treatment for patients with opioid use disorder.
- 18. Solutions continued ● The 2016 “Guidelines for the Management of Postoperative Pain” was created because less than half of surgical patients reported adequate pain management. ○ 1. Preoperative education and perioperative pain management planning ○ 2. Multimodal therapy for the management of postoperative pain ○ 3. Use of physical modalities: ■ Transcutaneous electrical nerve stimulation (TENS), acupuncture, massage and cold therapy. ○ 4. Use of systemic pharmacological therapies: ■ NSAIDs and acetaminophen, preoperative dose of oral celecoxib, gabapentin or pregabalin (Lyrica). ○ 5. Use of local pharmacological therapies and peripheral regional anesthesia: ■ Nerve blocks and clonidine as an adjunct to prolong peripheral nerve blocks.
- 19. Solutions continued ● The CDC has initiated a program to fund aid to 16 states (including SC) for: ○ Maximizing Prescription Drug Monitoring Programs ○ Community or Insurer/Health Systems Interventions ○ Policy Evaluations ○ Rapid Response Project - The initiative runs through 2019 - States will be provided between $750,000 - $1,000,000 ● Opioid antagonists: ○ Naloxone
- 20. Review ★ Nearly 100 million Americans are dealing with chronic pain. ★ Opioid prescriptions have quadrupled in the last decade. ★ Prescription opioid overdoses leading to death have quadrupled in the last decade. ★ Addiction disorders occur in at least 5% of patients who use their prescription correctly. ★ Dependence or abuse of prescription opioids increases heroin dependence or abuse 40X. ★ Heroin is reported to be easier to obtain and cheaper than Rx opioids while providing equal relief. ★ Personal risk factors for prescription opioid dependence are unique and variable and pain management should tailor to this.
- 21. Questions?
Editor's Notes
- Today I’m going to speak about the opiate epidemic as it relates to pain management. I wanted to study this relationship because opioids are most commonly prescribed as analgesics and there has been a large increase in Rx opioids and opioid overdose deaths recently. https://www.nhms.org/sites/default/files/Pdfs/Safely_Tapering_Opioids.pdf
- Analgesic Euphoria
- Hyperalgesia - increase in pain sensitivity
- Tolerance, or requiring an increasing dose of the opioid for pain relief, frequently occurs. The mechanism behind tolerance of opioids is still unclear Different opioids seem to have different ways of cause tolerance Some ideas on this include receptor downregulation, endocytosis of receptors (able to be recycled), and uncoupling of receptors from their downstream signaling pathways. Rx drugs are misused more than any other drugs except marijuana and alcohol. This is probably the result of many factors including: availability, euphoric effect, and the ease of developing dependence. Risk factors for becoming dependent on Rx opioids include: History of opioid abuse, Genetics (mu receptor genes), age, depression, psychotropic medication use Since we have learned that addiction is a brain disease, it is fitting that dopamine receptors have been observed to decrease in people addicted to opioids. One study showed that 25% of out-patients struggled with addiction to their prescribed opioid NIDA states that “ an addiction disorder occurs in about 5% of people who take opioid pain relievers AS DIRECTED over one year!!!! This is very concerning since misuse is so common.
- The DSM-5 describes opioid use disorder as continuing to use opioids regardless of negative consequences. The individual must exhibit at least 2 of the following criteria within a year.
- Prescription opioids are either opiates which are natural or opioids which are synthetic. Morphine and heroin are opiates while methadone and oxycotin are opioids. Prescriptions of opioids quadrupled from 1999 to 2014 with 1 in 5 non-cancer pain patients receiving an opioid Rx The practices that prescribe opioids the most are pain medicine, surgery, and rehabilitation However, primary care providers account for the DISPENSING of about half of these. This map from 2012 shows the number of prescriptions per 100 people for each state. The dark purple is the highest rate. This picture from the CDC explains that everyday over 1000 people are treated in the ER for NOT using prescription opioids as directed. This is why the statistic mentioned earlier about 5% becoming addicted with proper use is so alarming. Finally, the opioids most commonly seen in overdose deaths are: Methadone, oxycodone, and hydrocodone.
- It might seem strange that opioids are so commonly prescribed but data shows that more than 100 million, or 20-30% of Americans suffer from chronic pain. This is more than the number with diabetes or heart disease. The impact of pain can be seen in the growing opiate epidemic as well as in pain’s cost to healthcare and the economy. Pain costs us around 600 billion dollars. I was unable to find a demographic breakdown of pain information.
- In the past decade, prescription opioid abuse has seen a shift in demographics including: The problem of abuse among youth is alarming:: Older adults are likely to experience more problems with smaller amounts of medications. This is because older adults experience increased medication sensitivity, slower metabolism and elimination. Older adults are also at a higher risk for medication misuse than the general population because of their elevated rates of pain, sleep disorders/insomnia, anxiety, and the chance of cognitive decline
- This image shows that the prescription opioids being used have become increasingly potent. Use of opioids stronger than morphine increased 20% from 1999 to 2012. Stronger drugs cause more intense effects and act quicker and therefore carry a higher risk of tolerance, dependence, and addiction. https://www.cdc.gov/nchs/data/dataBriefs/db189.pdf
- Non -medical users get their opioids in multiple ways. Alarmingly, more and more are people obtaining these drugs through a prescription from at least one physician. Physician prescribed opioids surpassed those being given away by friends and families to non-medical users! This shows that non-medical users have discovered they can easily legitimize their drug misuse. While there are protocols for prescribing opioids, these do not make it any easier for physicians to measure their patients’ pain. Unfortunately, if guidelines aimed at reducing the number of opioid prescriptions are enforced, legitimate pain patients often suffer while misusers may be diverted to other methods of obtaining opioids (including heroin) if they do not accept psychological treatment they really need. Physicians are faced with the paradox of causing patients pain and offering help to opioid misusers. Misusers may be diverted to easier to obtain opioids - including heroin, or accept the psychological treatment they really need.
- https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf
- In the recent epidemic, illicit opioids have become an increasing problem. In particular heroin. The picture compares heroin with the common prescription opioid oxycotin. Prescription opioids are closely tied to the spike in heroin use Dependence on or abuse of Rx opioids is associated with a 40-fold increased risk of dependence or abuse of heroin. A NSDUH survey reported that less than 4% of people who had abused Rx opioids started using heroin within 5 years. This low rate may be because most people who transition to heroin tend to be frequent polydrug users. The data wasn’t clear about what other kind of drugs were frequently used in this situation. So i’m not sure if many people with comorbidities and therefore multiple Rxs would fall into this category as well. A survey of addicts undergoing treatment showed that 94% switched to heroin because Rx opioids were more expensive and harder to obtain. One of America’s biggest heroin suppliers is mexico. Mexico saw a 6-fold production increase in just 4 years! The problem with Rx opioids isn’t limited to heroin use. 12.7% of new illicit drug users began with Rx pain relievers! This chart shows a breakdown of demographics with increased heroin use: More women, more 18-25 year olds and 26+ More non-hispanic whites More in every income bracket More in uninsured and privately insured individuals but NO increase among those on medicaid
- Several solutions have been proposed for the problem of prescription opioids leading to drug misuse and abuse. First i’ll mention the CDC’s “guideline for prescribing opioids for chronic pain” This was published last march. All of the guidelines are listed, but some of the most important include: Using non-opioid pharmacologic therapy for chronic pain Establishing treatment goals Using immediate-release opioids Starting with the lowest dose and gradually increasing the dose Frequent monitoring AND Use of urine drug tests before starting There has been substantial patient pushback towards this. long -term opioid users have had their prescription reduced.THIS CAN LEAD to LOW COMPLIANCE and TX DISCONTINUATION!!! Many report inadequate pain management because doctors are becoming too strict.
- Another guide targets pain treatment after surgery. the 2016 Guidelines for the management of postoperative pain because surgery is a common reason for being prescribed an opioid. This guide includes: Preop education and perioperative pain management planning Multimodal therapy postoperatively Use of physical modalities like transcutaenous electrical nerve stimulation and acupuncture Use of systemic pharmacological therapies - other than opioids AND use of local pharmacological therapies and peripheral regional anesthesia - like prolonged nerve blocks.
- The CDC also has initiated a program to fund aid to 16 states including SC for: This will run through 2019 and provide states between 750k-1million Finally, as we learned Tuesday opioid antagonists such as naloxone are available in some states.