Opioid Abuse

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130 Americans die every day due to opiate overdoses. These occur from both illicit and prescribed users of opiates. In recent years, the opiate epidemic has become a mainstream health issue, and opioid abuse was brought to center stage when the President of the United States declared the opioid abuse crisis a public health emergency. 

The current crisis is a combination of both licit and prescribed users, but the root of the issue remains an ease-of-access for opiate drugs and synthetics. Nurses can play a pivotal role in curbing the epidemic by being knowledgeable about opiate use disorders, the risks of opiates, and alternatives for pain control. Nurses can use the knowledge in this course help change the course of patients and reduce the risk of opioid abuse. 

What are Opiates?

Opiates are powerful substances which are commonly used to alleviate both acute and chronic pain. The history of opioid abuse goes back many thousands of years. The first recorded reference is from 3,400 B.C. when opium was cultivated in southwest Asia. There were even wars fought over the previous flow in the mid 1800s (1). Perhaps the most famous historical event related to opium was the advent of “opium dens”. These were underground “dens” where opium was bought, sold, and utilized; this was a very early but concerning form of opioid abuse (1). Much like today, the addictive properties of opium overcame many individuals and caused great harm to the world and communities as a whole. Indeed, the opiate epidemic of the 2000s is not the first in modern history, though it is much different and more severe than previous epidemics.

Today, opiates are used for both acute and chronic pain. The ability to quickly, reliably, and (when used appropriately) safely reduce pain is what makes the drug class so valuable. Many common drugs are opiate derivatives or synthetics, including morphine, codeine, oxycodone, heroin, hydromorphone, and fentanyl.

In the United States, opiates are considered controlled substances and the majority of them are classified as schedule II  (with heroin classified as schedule I) (2). Opiates will always have a place in medicine and treatment of pain and are incredibly useful; however, the current opiate epidemic in America makes evident the potential consequences of opiate abuse.

Preventing Opioid Abuse, Misuse, and Harm

Every day 190 Americans die of opiate overdose (3). Additionally, there are 4.3 million Americans each month who engage in the non-medical (non-prescribed or illicit) use of opiates (5).  However, it is key to remember that opioid abuse or opiate-related deaths are not the only negative consequences. There are many overdoses which do not end in death, and on the other end of the spectrum, many negative effects do not cause death. Addiction can cause losses of employment, damage to relationships, psychological distress, homelessness, and many more negative side effects.

So, how do healthcare professionals help reduce the impact of opiate addiction and misuse? The approach must be multi-modal - aimed at primary, secondary, and tertiary prevention.

• Primary prevention includes appropriate opiate prescribing, risk stratification with patients, and generally preventing opiate addiction.
• Secondary prevention is aimed at mitigating the effects of opiate addiction. This includes rehabilitation and cessation of opiates in addicted individuals, ideally in favor of non-opiate treatment options.
• Tertiary prevention is the reduction in harm from opiate addiction and overdose. This includes resuscitation of overdose patients and helping patients recover from the effects of opiate addiction.

Appropriate Prescribing

The Centers for Disease Control and Prevention (CDC) offers excellent guidance on how to appropriately prescribe opiates, though it will continue to require a great deal of knowledge and effort from individual prescribers and managers of chronic pain. For the purpose of this article, we will focus on CDC recommendations. Below we will discuss the 12 key points of opiate management, per the CDC.

Opioids Are Not First-Line Therapy

“Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate“ (5).

Author’s Input

Many patients experience pain. Pain is indeed one of the most common complaints in primary care offices. When dealing with chronic pain, we should consider ALL non-opiate therapies for patients prior to prescribing opiates. This can include physical therapy, meditation, exercise / movement, treatment of underlying depression and/or psychiatric issues, meditation, modification of aggravating factors, and many more interventions. In some cases, none of these alone or combined will be enough to provide satisfactory relief, but we must utilize non-opiate and non-pharmacological solutions as much as possible to reduce opioid abuse, and dose (if opiates are necessary).

Establish Goals for Pain and Function

“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“ (5).

Author’s Input

Many patients erroneously believe that cessation of pain is the goal of therapy. This is not based on fact nor is it reasonable, as many patients (even with opiate therapy) will not have complete remission of pain. The goal of the clinician should be to work with the patient to provide minimal risk intervention that will provide acceptable pain control.

Discuss Risks and Benefits

“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” (5).

Author's Input

A prescription for an opiate should never be written to a patient without a thorough discussion of risks and benefits. The clinician must first be convinced that the risk to benefit favors prescribing an opiate. Then, the clinician must discuss rationale with the patient. An individual assessment regarding the risks should be provided to each and every patient.

Prescribe Immediate-Release Opioids First

“When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/ long-acting (ER/LA) opioids” (5).

Author's Input

Extended-release opioids have been associated with higher rates of overdose and higher potential for opioid abuse. Immediate-release opioids should be utilized first, whenever possible.

Use the Lowest Effective Dose

"When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to >90 MME/day, and should avoid increasing dosage >90 MME/day or carefully justify a decision to titrate dosage to >90 MME/day." (5).

Author’s Input

The clinician must keep in mind that the “minimum required dose” may change over time. As a patient implements more non-pharmacologic interventions, the required dose may decrease. Conversely, there can be some degree of tachyphylaxis with opiates and the required dose may therefore increase. Dose titration requires careful judgement on the part of the prescribing clinician.

Prescribe Short Durations for Acute Pain

"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” (5).

Author's Input

It is well established that chronic opioid therapy is not the most effective therapy for pain management. Clinicians should consider adjuncts for ongoing or chronic pain patients.

Evaluate Benefits and Harms Frequently

“Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids” (5).

Author’s Input

Is it important that clinicians consider changing circumstances. A patient’s health status or life circumstances may change such that opiate therapy benefits no longer outweigh the harm, or vice-versa.

Use Strategies to Mitigate Risk

"Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day)” (5).

Author's Input

Naloxone therapy should be considered for all patients who are at high risk of opioid overdose.

Review Prescription Drug Monitoring Program Data

“Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months” (5).

Author's Input

Each state has robust data regarding prescription medication; utilizing this data can help reduce opioid misappropriation and concurrent prescriptions ("doctor shopping").

Use Urine Drug Testing

"When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.” (5).

Author’s Input

The author recommends that clinicians take great care in this area. Indeed, drug testing can help identify those who are already abusing other substances, but it can also harm the trusting relationship developed between a patient and clinician. The patient should be re-assured that the testing is performed for their own good and out of concern for their own health, rather than punitively or because the clinician “mistrusts” them, as these may be the default thoughts of many patients.

Avoid Concurrent Opioid and Benzodiazepine Prescribing

"Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently 'whenever possible' "(5).

Author's Input

The highest risk of overdose of opioid abuse is commonly seen when opiates and benzodizepine (or any combination of sedating medications) are prescribed concurrently, especially in conjunction with alcohol. For this reason, clinicians should strongly consider avoiding such risks and only prescribe this combination when absolutely necessary.

Offer Treatment for Opioid Abuse Disorder (OAD)

"Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid abuse disorder” (5).

Author's Input

In acute cares settings, clinicians often view OAD as a secondary illness and frequently leave it unaddressed. However, there are now effective treatments for OAD. Given the significant morbidity, mortality, and associated quality of life issues arising, patients with OAD should be offered treatment, even if it not the primary reason for treatment.

Nurses' Responsibility

As a nurse treating patients, it is your responsibility to advocate for the patient’s best interests. Nurses can intervene at any juncture in a patient’s care to advocate for appropriately prescribed opiates.

Risk Factors for Opioid Abuse, Opiate Harm or Misuse

The risk to benefit has been discussed many times previously and is frequently referenced by the CDC. The benefits of opiate therapy are typically obvious (reduced pain, increased quality of life, etc.), but the risks are less often discussed. So how do nurses know who is at higher risk of the negative effects of opiates?

According to the CDC, the major risk factors are:

• Illegal drug use; prescription drug use for non-medical reasons.
• History of substance use disorder or overdose.
• Mental health conditions (ergo depression, or anxiety).
• Sleep-disordered breathing.
• Concurrent benzodiazepine use (6).

Mortality rates from opioid abuse are highest in those who are middle-aged, have psychiatric conditions, and/or have previously abused substances (7). It is important that clinicians utilize this information when considering risks and benefits associated with opiate therapy. (See the CDC's Drug Overdose Deaths page for current mortality rates).

Image source: CDC

Image source: CDC

Signs of Opioid Abuse, Diversion, and Addiction

Clinicians should remain vigilant for signs of opioid abuse disorder, as it can occur in any patient (even those not prescribed opiates). Opiate use disorder is characterized in the DSM-5 as a desire to utilize opiates despite social and professional consequences (12). It includes dependence and addiction, with addiction being on the severe end of the spectrum (12). Opiate use disorder can be diagnosed when at least two of the following are observed in a 12-month period:

1. Opioids are often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid abuse.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
4. Craving, a strong desire, or urge to abuse opioids.
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued opioid abuse despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
7. Important social, occupational, or recreational activities given up or reduced because of opioid use.
8. Recurrent opioid use in situations in which it is physically hazardous.
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Exhibits tolerance (discussed in the next section).
11. Exhibits withdrawal (discussed in the next section) (13).

Urine drug screening can be useful in patients with suspected opiate abuse disorder as it may identify concurrently abused substances. If a patient is identified as having opiate abuse disorder the “risk” side of the “risk-to-benefit” equation is now shifted, and the continued use should be carefully weighed against the potential for negative effects, including addiction. Addiction is defined as continued substance use despite adverse events or consequences (12).

For those prescribed opiates, clinicians should have candid conversations about the risks of continued use for those with OAD. The CDC offers some creative examples of how to discuss the condition with patients, which nurses may find helpful in their interactions. (Below are only examples; the wording depends on the exemplifying patient's specific scenario and needs):

"Trouble controlling the use of opioid medication makes it unsafe, and long-term risk over time is substantial."

"The medicine has become a problem in itself. You have developed a known complication of therapy that we should not ignore."

"Continuing the current medication is not a reasonable option due to the risks, but there are options for treating what we call opioid use disorder, also known as OUD."

"It seems as if you are running out of your medication more quickly than anticipated."

"Sometimes people become too comfortable with the medications and start to take them for reasons other than pain."

"You meet the criteria for opioid use disorder, also known as OUD. It's helpful to put a name on it because it opens up a variety of approaches to help with your specific circumstance." (All derived from source 13).

Once a nurse identifies a patient with OAD, what should be done? At this point, as above, a candid conversation with the patient must occur. Then, a treatment plan should be formulated, which would include a careful consideration for discontinuing the opiate (if feasible). This provides an excellent transition into our next section, opiate alternatives.

Opiate Alternatives

Opiate alternatives can be broadly classified as pharmacologic and non-pharmacologic. We will first discuss pharmacologic alternatives.

Pharmacologic

Acetaminophen

Commonly known as Tylenol™. Tylenol™ is  an over-the-counter drug and has a very favorable safety profile when utilized correctly. Acetaminophen is considered first-line therapy in any pain management regimen (9).

NSAIDS

NSAIDS can be very powerful in pain management, as many pain conditions are related to inflammation. However, patient tolerance can be an issue with chronic NSAID exposure. Indeed, many clinicians shy away from NSAIDS due to the perceived risk profile (9).

Tricyclic Antidepressants (TCAs)

Tricyclic Antidepressants (TCAs) provide significant pain relief to many patients, as they have the unique ability to modify the perceptions of pain (5). However, tricyclics have many side effects of their own and thus have been generally phased-out in lieu of newer antidepressants. Thus, in the pain realm, they should be considered for certain patients - particularly those with concurrent untreated depression.

SSRI Antidepressants

SSRIs are typically tolerated better than tricyclics (9) but again are not recommend for first-line analgesia. SSRIs are typically reserved for those with concurrent psychiatric illness which may benefit from the overall effect of the drug, and on a case-by-case basis for select patients.

Muscle Relaxants

Medications such as gabapentin can be very useful especially in pain originating from musculoskeletal causes. However, the mechanism of action is poorly understood (9) and side effects can be troublesome. In one study, approximately 25% of patients taking muscle relaxants for chronic pain discontinued the agents due to adverse effects.

Topicals

Many topical agents now exist, including NSAIDS (9). Topicals are typically considered analgesic-sparing rather than standalone treatment (9). The American College of Rheumatology has excellent and detailed guidance on how to utilize topicals, which deserve a course of their own.

Corticosteroids

Corticosteroids have very potent anti-inflammatory effects (9) and have a proven role in pain management. Short-term therapy is typically favored over long-term therapy due to the potential issues of long-term systemic therapy (osteoporosis, immunosuppression, risk of serious or fatal infections, weight gain, muscle weakness, diabetes, Cushing’s syndrome, hypertension, glaucoma and cataracts). Though some serious adverse events can occur with short-term therapy (psychosis, anxiety, avascular necrosis, etc.) (9). Corticosteroids can be beneficial for patients with acute pain. Perhaps the best use of these agents is in targeted (injectable) delivery.

Non-Pharmacologic

These therapies will be discussed less in depth, as they typically require referrals for treatment. However, it is important that nurses are aware of the existence of these therapies, and are able to make appropriate referrals and recommendations. Physical therapy consults are invaluable as they often utilize many of the tools below and offer more knowledge about non-pharmacologic therapies in general:

• Psychological interventions (including distraction, stress management, hypnosis, and other cognitive-behavioral interventions),
• Acupuncture and acupressure,
• Transcutaneous electrical nerve stimulation,
• Physical therapies (including massage, heat/cold, physiotherapy, osteopathy, and chiropractic). (10).

Use of these methods could help reduce opioid abuse.

Conclusion

Nurses should view non-pharmacologic therapies as “tools” available to help patients dealing with acute and chronic pain. Though opiate therapy is a valuable tool as well, its potential negative effects are often under-considered, and the rate of opiate prescription currently is excessive, which can lead to opioid abuse (10).

When evaluating patients with pain, nurses should work with patients and providers to ensure that the patient is on an optimal pain regimen, which ideally should include both pharmacologic and non-pharmacologic therapies. Seeking referral and consultation from relevant professionals can also be very powerful in pain management (physical therapists, chiropractors, psychiatrists, etc.).

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