Techniques aid safe opioid prescribing
NASHVILLE – The number of opioid prescriptions filled in U.S. pharmacies has tripled since the early 90s, skyrocketing from 76 million in 1991 to 219 million in 2001. During this time period, ED visits from opioid misuse or abuse and drug overdose deaths associated with the medication have also risen sharply.
Emergency department visits attributable to opioids increased from 600,000 to more than 1.2 million from 2004 to 2010, and overdose deaths have quadrupled from 4,000 to more than 12,000 annually from 1999 to 2010, data from the Substance Abuse and Mental Health Services Administration indicate.
“As a result many states are enacting legislation to ensure appropriate, safe opioid prescribing,” Brett Badgley Snodgrass, MSN, APRN, FNP-C, of Comprehensive Primary Care in Bartlett, Tenn., said at the American Association of Nurse Practitioners 2014 meeting.
“Safe prescribing is of utmost importance, primarily to decrease diversion and abuse, but also to make it as safe and appropriate for our patients,” she said.
Safe, effective chronic pain management should encompass urine drug testing, risk stratification and pharmacogenetic testing, as needed.
“Drug screening is one of the elements we use in guiding our prescriptive habits when we're talking about opiates or controlled substances. It absolutely should be used in practice. How often depends on state mandates, the individual prescriber and the patient,” Snodgrass said.
Drug test helps providers determine if patients are taking their medications as prescribed, and also if they are taking other drugs that may interfere with their medications. There are a variety of screening methods available, including urine, blood immunoassays, and gas chromatography/mass spectrometry (GC/MS).
“Urine drug screening is the easiest and most reliable way to obtain drug screening. It's quick, so you can get a point of care test and have some working knowledge of what is in that patient's urine when they leave your office,” Snodgrass said.
When interpreting point of care test results, clinicians should assess the risk of false positives or negatives, and should not make definitive decisions based on findings. If a urine drug test yields an unexpected finding, providers should limit the provision of the opioid to a seven to 14 day period.
Clinicians should also be aware that some medication use or abuse may go undetected on a point-of-care test. Prescription drugs such as fentanyl, oxycodone and carisoprodol are often omitted, certain opioid normetabolites may not react (typically <0.1%), and high thresholds are typically used in point –of-care tests.
“Take into account what's going on with the patient when you consider drug testing. If they're a higher risk patient then you're going to urine drug screen them more often,” Snodgrass said.
Confirmation testing with more accurate methods such as GC/MS should be performed prior to making a final care decision, she advised.
It's also important for clinicians to monitor patient responses to treatment, due to variation drug metabolism from patient to patient that can result in wide variations in clinical effect.
Genomic testing to detect genetic predispositions such as allelic variation in the CYP2D6 and CYP2C19 genes, which can markedly increase or decrease drug metabolism, is a new trend in opioid management.
“Genomics can improve diagnostic and prescribing accuracy and speed,” Snodgrass said. “It's helping with patients that are hard to treat – those in which no medications work, those that become very sedated with low doses of medication, those who are on high doses that are still not getting appropriate effects with appropriate dosing.”
Weaning is another key aspect in managing patients taking opioids – either as a natural course of therapy when pain scores decrease and a patient has recovered, or when a patient is displaying aberrant or divertive behavior.
Signs of aberrant behavior include doctor-shopping, multiple instances of dose escalation, failure to comply with dosing instructions, inappropriate drug testing results and obtaining opioids from multiple providers.
“Other reasons for which you would wean are if a patient is not getting appropriate pain relief from higher doses and you've tried to titrate them appropriately to a dose where they should be getting some adequate relief,” Snodgrass said.
No matter what the reason, the clinician's main goal should be preventing withdrawal symptoms. Most opioids can be weaned safely with a 10% to 20% weekly decrease.
Be sure to outline the reasons for weaning and written instructions for the weaning process in a provider patient agreement signed by the patient.
During the weaning period, patients should undergo a urine drug test at each visit to monitor progress. Once a drug screen is negative for the product you are weaning, continued wean is no longer necessary.
Consider a rotation to another opiate or maybe consider other alternatives, like nonopioid therapies.
“Treating pain is not parallel to opiate use. We need to consider all other alternatives when we are prescribing. Consider anti-inflammatory medications, anticonvulsants and mood modulators. Those are very important in treating our pain patients,” Snodgrass said. “Also consider lifestyle therapies such as yoga, exercise and acupuncture. We have evidence-based information that shows us that those things work.”
On the flip side, she added that healthcare providers should not be afraid to use an opioid when its appropriate. Some patients truly have no other options, such as elderly patients in whom other medications are contraindicated and can actually have worse outcomes than treatment with opioids. For these patients, Snodgrass advised starting dosages low and titrating doses higher very slowly.