HEALTH CARE PROVIDERS
Research on opioid misuse, and the effectiveness of prevention efforts in this area, allows healthcare professionals to continuously improve their approach to working with patients in need. Below we have included information about the latest research, important resources, and other helpful tools for clinicians.
CDC Guidelines for Practice
The Centers for Disease Control and Prevention (CDC) has published guidelines for prescribing opioids. These guidelines are for treating patients in pain from non-cancer sources. The guidelines are not intended for treatment of pain in patients in active cancer treatment, palliative care, or end-of-life care. To access the CDC guidelines, click here.
In December 2018, two directives were released regarding the co-prescription of naloxone with opioids. The U.S. Department of Health and Human Services (HHS) put out a guidance recommending that clinicians prescribe or co-prescribe naloxone “to individuals at risk for opioid overdose including, but not limited to: Individuals who are on relatively high doses of opioids, take other medications which enhance opioid complications, or have underlying health conditions.” The HHS statement also recommends that clinicians educate patients, family members, and friends about when and how to use naloxone. In addition, an FDA advisory committee voted in favor of adding language to the drug label on opioid medications recommending the co-prescription of naloxone to all or some patients.
HHS Guide on Tapering Opioids
In October 2019, the United States Department of Health and Human Services (HHS) published a guide for clinicians who may be considering reducing opioid dosage or discontinuing long-term opioid therapy for chronic pain. The HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics is available here.
Federal Policy Changes in Response to Covid-19
New policies have been enacted by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Agency (DEA), giving providers more flexibility in providing methadone and buprenorphine to patients with opioid use disorders in response to the challenges in treating these patients during the Covid-19 pandemic.
In late March, SAMHSA issued a guidance that allows states to permit all patients who are on a stable methadone dose to receive up to 28 days of take-home medication, and for patients who are less stable to receive up to 14 days of take-home medication.
The DEA waived a requirement that patients who wish to begin buprenorphine treatment must have an in-person consultation with the prescriber. This change allows those seeking buprenorphine treatment to be prescribed the medication after consulting with a waivered prescriber via telemedicine.
Pain Management during Covid-19
A recent article was published with consensus recommendations for caring for patients with pain during the Covid-19 pandemic. The authors assembled an international panel of experts to formulate recommendations to guide practice. The recommendations were based on the best available evidence and recommendations at the time of writing.
With respect to prescribing opioids during the Covid-19 pandemic, the panel recommended:
- Using telemedicine to evaluate, initiate, and continue opioid prescriptions
- Ensuring all patients receive their appropriate prescription to avoid withdrawal
- Naloxone education and prescription for high risk patients
- Informing patients of the risks and impact of long-term opioid therapy on the immune system
- Communicating with other healthcare professionals (e.g., family physicians, pharmacists, nurses)
The panel further advised that safe opioid prescribing procedures be performed, even though controlled substances may be provided without a direct in-person evaluation. Safe prescribing procedures include:
- Assessing for adequate response, adverse events, aberrant behaviors, functioning, and quality of life improvement
- Performing pill counts
- Obtaining informed consent via video communication
- Educating patients on the risks and benefits of opioids
- Prescribing Naloxone when appropriate
- Continuing review of medical history and medications that impact opioid prescribing
- Any significant, sustained increase in opioid dosage requires an in-person evaluation
For a summary of therapeutic considerations and recommendations for chronic pain management during the COVID-19 pandemic from this group, see Table 1.
In the United States, a group of experts also recently convened to establish guidelines for best practices for pain management during the Covid-19 pandemic. The panel included experts from various stakeholders, including the U.S, military, Veterans Health Administration, and academia. This best practices guideline was published by the American Academy of Pain Medicine. To access the complete guideline, click here.
Retention rates among those receiving treatment are low. For those receiving medication-assisted treatment without any psychosocial treatment, the two-year retention rate is 38%. However, the two year-retention rate increases to 53% when medication-assisted treatment is combined with cognitive behavioral treatment.
In December 2018, the FDA also approved the marketing of a new phone app to help patients with opioid use disorders remain in treatment. The new app, called reSET-O, is for outpatients with OUD who are receiving the medication buprenorphine in combination with psychosocial treatment. The app, which requires a doctor’s prescription but can be downloaded directly to a patient’s mobile device, delivers a series of interactive cognitive behavioral therapy sessions and includes a reward system for compliance. A recent clinical trial found that patients who used the reSET-O were significantly more likely to remain in a 12-week treatment program for opioid use disorder than those who did not. Retaining persons with opioid use disorder in treatment longer reduces the likelihood of relapse.
PREGNANT AND POSTPARTUM WOMEN AND CHILDREN
Opioid use by pregnant women is a significant concern because opioids can have adverse effects on both the mother and her baby (preterm labor, stillbirth, neonatal abstinence/opioid withdrawal syndrome (NAS/NOWS), maternal mortality). Opioid use disorder rates at delivery increased more than fourfold from 1999-2014, from 1.5 to 6.5 cases per 1000 deliveries. According to the most recent data available, the national incidence rate of NAS/NOWS was 7 cases per 1000 hospital births in 2016. In 2017, the incidence in Massachusetts was 13.7 per 1000 hospital births, a rate significantly higher than the national average.
Pregnant women who seek treatment for opioid dependence have better outcomes than pregnant women who quit abruptly. If a woman is unable to quit before becoming pregnant, treatment with methadone or buprenorphine during pregnancy improves the chances of having a healthier baby at birth.
The CDC and the American College of Obstetricians and Gynecologists (ACOG) both recommend that clinicians prescribing opioids should discuss the risks of opioid use in pregnancy and provide contraception counseling. The ACOG also recommends universal substance use screening at the first prenatal visit and medication-assisted treatment for pregnant women when possible and appropriate. Clinicians should consider arranging for such women to deliver at facilities that are prepared to monitor and care for infants with NOWS. Moreover, after delivery, these women might need referrals to postpartum psychosocial support services, substance use treatment, and relapse prevention programs.
In addition, while some progress has been made in recent years in spreading awareness about the dangers of opioid use by childbearing women, middle-aged women remain at very high risk for both prescription and illicit opioid overdose. The CDC recently reported that, between 1999 and 2017, the rate of deaths involving prescription opioids increased almost five-fold (485%) in women in the 30-64 age group; the rate of overdose deaths involving synthetic opioids and heroin increased even more dramatically (1,643% and 915%, respectively). Deaths involving prescription opioids rose in every age group over this 18-year-period, but the largest increase (more than 1000%) was recorded for women in the 55-64 age group, suggesting a need for resources to be specifically targeted toward this at-risk group.
Non-fatal opioid overdoses have also led to an overwhelming increase in hospitalizations and emergency department visits. This trend has also impacted children’s hospitals in the United States. A recent study showed that the number of children (aged 1-17) admitted to the PICU for opioid overdoses doubled between 2004 and 2015. Thirty-seven percent of these young patients needed mechanical ventilation and 20% required vasopressors. In addition, methadone accounted for nearly 20% of the opioid overdoses among patients between the ages of 1 and 5. This finding suggests an increased risk to young children when parents or family members are using methadone or being treated for their own opioid addiction. The study authors called for increased efforts to reduce preventable opioid exposure to children, such as by pediatricians reminding parents to lock up all medications.
Healthcare providers prescribing opioids can screen patients for prescription opioid use disorder at regular intervals. Screening questionnaires, such as the Current Opioid Misuse Measure (COMM) and the WHO ASSIST, were specifically developed for use in pain clinics and primary care settings. Screening and brief intervention provide an opportunity for clinicians to intervene early and improve outcomes.
Screening instruments are used as an additional source of information, not as a replacement for clinical judgment and other forms of monitoring, such as prescription monitoring data or urine screens.
The CDC recommends checking the Prescription Drug Monitoring Program (PDMP) data for prescriptions from other providers and doing urine drug testing to identify prescribed substances, ensure adherence to presribed medications, and identify undisclosed use. PDMPs are helpful when the profile is concerning, but they do not exclude the possibility of an opioid use disorder.
Patients with pain and opioid use disorders are at a significantly increased risk of suicide. In fact, the number of firearm suicides in this population is even greater than the number of overdose suicides. Clinicians should screen for suicide risk in this population and discuss the importance of securing access to all lethal means, not just pills, with these patients and their loved ones.
While there is significant overlap, those who intentionally overdose on opioids and those who unintentionally overdose are likely distinct groups with distinct clinical correlates. For example, more females intentionally overdose, whereas more males accidentally overdose. In addition to gender, risk factors for suicide among opioid users include higher dose, older age, comorbid disorder, and a low sense of belonging. Preventing opioid suicides may require a public health response that is different from the current response, which is currently aimed at preventing unintentional fentanyl overdoses.
Every emergency department patient who comes in with an overdose should be screened for suicide risk, so that they can be referred for appropriate treatment. The Columbia Protocol provides a screener with triage specifically for use in emergency departments. To access this screening instrument, click here.
These suicide assessment questions are helpful to clinicians in inquiring about specific aspects of suicidal thoughts, plans, and behavior. The questions have been excerpted from the American Psychiatric Association’s Practice Guidelines.
Another recommended suicide assessment is the SAFE-T developed by Dr. Douglas Jacobs in conjunction with SAMSHA. The SAFE-T can be downloaded here.
There is a strong association between opioid use disorders and other forms of psychopathology. Patients who present with psychiatric disorders and substance use disorders are more likely to receive prescription opioids and long-term opioid therapy. They are also more likely to be prescribed concurrent sedative-hypnotics and to have more physical pain. These patients require complex management. Optimal care for such patients requires that primary care, mental health, and substance use disorder treatment be integrated well.
Individuals who die by opioid overdose often have other drugs in their system in addition to the opioid. Fentanyl is found not only in combination with heroin, but also with counterfeit pills and cocaine. Overdose deaths involving antidepressants or benzodiazepines appear to be mainly driven by the combination of these prescription drugs with an opioid (NIDA, 2020).
In the United States, there has been an increase in the number of opioid overdose deaths in which stimulants are also present. Barocas and colleagues (2019) studied the 2244 opioid-related overdose deaths in Massachusetts between 2014 and 2015 that had accompanying toxicology results. They found that 36% of these deaths involved opioids plus stimulants, 46% involved opioids plus another non-stimulant substance. Thus, five out of every six Massachusetts residents who die from an opioid-related overdose had another substance in their system in addition to the opioid.
The extent to which overdoses involving opioids in combination with a stimulant are due to fentanyl contamination of the methamphetamine supply or intentional simultaneous use (e.g., mixing heroin and cocaine as a speedball; using the opioid to come down from a methamphetamine high) is not yet known. However, we do know that polysubstance use increases the risk of fatal overdose and poses substantially greater treatment challenges. Given that persons with comorbid mental illness accounted for more than half of all opioid overdose deaths in the Massachusetts study, reducing barriers to mental health services may help to mitigate the risk of polysubstance use and overdose deaths (Barocas and colleagues).
Those who use opioids and methamphetamines may be at increased risk of complications from Covid-19. These populations have a higher prevalence of tobacco use and of pre-existing medical conditions (Davis & Samuels, 2020). In Massachusetts, an estimated 20,374 persons are living with HIV infection and 38,100 persons are living with Hepatitis C. Many HIV cases (26-33%), and most HCV cases (86.6%), are contracted from intravenous drug use (NIDA, 2020). In addition, methamphetamine use can cause pulmonary damage, pulmonary hypertension, and cardiomyopathy, which are known risk factors for a more severe course with Covid-19 (Dunlop et al., 2020; Volkow, 2020).
OUD AND THE BLACK/AFRICAN AMERICAN COMMUNITY
Although attention to the opioid overdose epidemic has largely been focused on White suburban and rural communities, opioid misuse and deaths are also devastating Black/African American communities across the United States.
The non-Hispanic Black population in the U.S. has about the same rate of opioid misuse as the national population. Similar to the overdose crisis broadly, synthetic opioid deaths from fentanyl and fentanyl analogs are driving the death toll. Between 2014 and 2017, death rates involving all opioids increased in the non-Hispanic Black population, but death rates involving synthetic opioids increased the most, by a staggering 818% (CDC, 2019; SAMHSA, 2019).
On the other hand, prescription opioid deaths are much lower in the non-Hispanic Black population compared to other racial and ethnic groups, likely due to lower prescribing rates. Racism has lead to systematic disparities in the treatment of pain. Studies have found that Black/African American individuals are significantly less likely than White patients to be prescribed opioids for pain, even when Black/African American patients self-report higher levels of pain (Chen et al., 2005; Heins et al., 2006; Pletcher et al., 2008; SAMHSA, 2019).
Treatment rates for opioid use disorders are already low in the general population, and especially low in Black/African American communities. SAMHSA recently issued a brief, which discusses the particular challenges that Black/African Americans face in accessing treatment and recovery services, including inequities in access to certain types of treatment, fear of legal consequences, and lack of culturally responsive care (SAMHSA, 2019).
Healthcare inequities and structural racism may prevent access to particular types of care. For example, individuals who are Black/African American, live in low-income areas, or do not have private insurance are less likely to have access to buprenorphine treatment (SAMHSA, 2019).
While the majority of individuals with substance use disorders in the United States are White, Black/African Americans have historically faced stricter legal consequences for drug offenses relative to Whites and higher rates of incarceration. In the case of an overdose, Black/African American individuals may be reluctant to seek naloxone from first responders due to mistrust of law enforcement. Prevention messages should be conveyed by trusted messengers within the community (SAMHSA, 2019).
For more information on community-informed strategies to address opioid use disorder in Black/African American communities, click here.
Resources for Providers
What is the NIH HEAL Initiative?
In April 2018, NIH Director, Dr. Francis S. Collins, announced the launch of the HEAL (Helping to End Addiction Long-term) Initiative, a trans-agency effort to speed scientific solutions to the opioid crisis. Through the initiative, NIH is supporting research to enhance pain management and improve treatment for opioid misuse and addiction. It is also seeking better long-term outcomes for babies with neonatal opioid withdrawal syndrome (NOWS).
The initiative is currently funding hundreds of projects nationwide. Click here to view opioid funding opportunities through the HEAL initiative.
Currently, there is a need for research evaluating the impact of the COVID-19 pandemic on persons with opioid use disorders, such as the effects of social isolation and quarantine. Research will also be necessary to evaluate whether the innovative ways we are approaching opioid use disorder during the pandemic are effective, and whether we might be able to integrate some of these methods into practice in the long term (Henry et al., 2020). Click here for more information related to COVID-19.
Additional Resources for Clinicians
- CDC Guidelines for Prescribing Opioids for Chronic Pain
- CDC Opioid Guideline Mobile App
- Opioid Overdose: Understanding the Epidemic
- SAMHSA Opioid Overdose Prevention Toolkit – 2018
- SAMHSA’s Medication-Assisted Treatment for Opioid Use Disorder Pocket Guide
- SAMHSA’s Treatment Improvement Protocol 63: Medications for Opioid Use Disorders
- Advisory: An Introduction to Extended-Release Injectable Naltrexone for the Treatment of People with Opioid Dependence – 2012
- Methadone Treatment for Pregnant Women – 2009