The State of Opioids in Health Care

Opioids have historically been considered a mainstay in pain management, Brant said. Their benefits include fewer systemic side effects, no end-organ toxicity, and improved quality of life and functional outcomes. However, improper patient selection and assessment, overprescribing, and borrowed or stolen prescriptions have affected opioid use.

According to Brant, more than 200,000 people died in the United States from 1999–2016 from overdoses related to prescription opioids. In addition, in 2016, more than 11.5 million Americans older than 12 years reported misusing prescription opioids, she said, and in individuals younger than 50 years, overdoses are the leading cause of death. Therefore, opioid management of pain in patients with potential substance use disorders should be handled using a case-based approach.

The Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A//www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm) is meant to improve patient-provider communication about the safety and effectiveness of opioid use for pain management; however, it does not apply to patients who are receiving active cancer treatment or palliative or end-of-life care, Brant said.

Brant also discussed knee-jerk reactions to the opioid epidemic, including providers’ refusal to prescribe opioids, rapid tapering of opioids, discontinuation of opioids because of any aberrant patient behavior, patients’ dismissal from a practice because of cannabinoid use, decreased opioid production, and an increased burden on palliative care teams.

Substance Use Disorders

According to Brant, 23 million Americans have a substance use disorder. These include alcohol, tobacco, cannabis, stimulant, hallucinogen, or opioid use disorders. Of those 23 million Americans, Brant said that only 10% receive treatment annually. In addition, Brant said that 22% of hospitalized patients have an active drug or alcohol use disorder; therefore, the standard approach recommended is universal precautions.

Universal Precautions Approach

The goals of the universal precautions approach are to:

• Protect patients.
• Protect practitioners.
• Protect access (to valuable therapies).
• Protect the community.
• Promote the cost-effective use of resources.

The universal precautions approach entails 10 steps:

• Diagnosis and differential (social and family histories, comorbidities, psychiatric diagnoses)
• Psychological and risk assessment (mental health screening, risk assessment tools, urine drug testing, prescription drug monitoring program)
• Informed consent (risks and benefits, therapeutic expectations, goals of treatment)
• Treatment agreement (behavioral expectations)
• Pre- and postintervention assessment (function, response to the intervention, continuity of care)
• Opioid trial (rational polypharmacy, goal for next visit, exit strategy)
• Reassessment (function, prescription drug monitoring program, urine drug testing)
• The six As (analgesia, activities of daily living, adverse events, aberrant behaviors, affect, adjuvants)
• Review of diagnosis and comorbidities (disease progression/evolution)
• Documentation (assessment and plan, treatment adherence, education, action plans, outcomes, monitoring, the six As)

Exit Strategy

Brant said that because all opioid prescriptions are trials, an exit strategy that promotes shared decision making with the patient should be in place. Opioids should be tapered gradually, and patients should be referred to a specialist for tapering. General medical care should also be continued, she said.

Preserving Hard-Earned Gains

According to Brant, risk assessment and the provision of safe pain care can help to prevent the development of substance use disorders. She said that, to prevent unintended individuals from being exposed to opioids, prescribing practices should be modified and patients and families should be educated. Advocacy is also imperative to prevent loss of access to opioids for those with cancer pain who may benefit from them, Brant said.