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 helpful tools for clinicians seeking to stay current about best practices in the field.
CDC Guidelines for Practice
The Centers for Disease Control and Prevention (CDC) has published guidelines for prescribing opioids. These are for treating patients in pain from non-cancer sources. These 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 came out 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 on 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.
Retention rates among those who are receiving treatment are low. The two-year retention rate for those receiving medication-assisted treatment, without any psychosocial treatment, is 38%. 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 syndrome (NAS), 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. This trend is consistent with an increased national incidence of NAS from 1999-2013.
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 NAS. 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.
There is no single instrument available which can predict those patients suitable for opioid therapy or identify those requiring more careful monitoring during therapy. The CDC recommends also checking the Prescription Drug Monitoring Program (PDMP) data for prescriptions from other providers and doing urine drug testing to identify prescribed substances and 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. It is available as a mobile app at the App Store or at Google Play under Suicide SAFE.
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.
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