Pain – Addiction Treatment Forum

From Opioid-Free to Long-Term User, In One Operation: Study Shows Key Role of Surgery

April 18, 2017

“Having surgery always comes with risks. But a new study suggests a new one to add to the usual list: the risk of becoming a long-term opioid user.

About 6 percent of people who hadn’t been taking opioids before their operation, but were prescribed the drugs to ease their post-surgery pain, were still getting the drugs three to six months later, the study finds.

That’s long after the window considered normal for surgical recovery, say the authors of the national study, published in JAMA Surgery. The rate didn’t differ between patients who had minor surgery and those who had major surgery, but it was slightly higher in southern states.”

Source: MedicalXpress.com – April 12, 2017

Why Women Use—and Misuse—Opioids

April 13, 2017

By Barbara Goodheart, ELS

How different are women from men, when it comes to using—and misusing—opioids?

More different than you might think, it turns out, according to CDC Vital Signs, a publication of the Centers for Disease Control and Prevention. Women are more likely than men to have chronic pain, and to use prescription opioids for longer periods, in higher doses. They also tend to become physically dependent on opioids more easily than men, even after using smaller amounts for shorter periods.

The outcomes of opioid use and misuse reflect women’s greater susceptibility. Between 1999 and 2010, overdose deaths from prescription pain killers increased 237% among men, but the rise was far higher among women—more than 400%.

The situation with heroin usage is similar. CDC Vital Signs indicates that between 2002 and 2013, heroin use rose 50% among men, but it increased 100% among women. These examples are from a new 35-page report, White Paper: Opioid Use, Misuse, and Overdose in Women, published in December by the Office on Women’s Health (OWH), U.S. Department of Health and Human Services (HHS).

This article summarizes the White Paper and highlights important data about women and opioid use and misuse.

Overview: The HHS White Paper

Contents. The White Paper opens with a description of the opioid epidemic and the three areas of the HHS Opioid Initiative (see table), then moves on to prevention and treatment of opioid use disorders (OUDs).

HHS Opioid Initiative

Focus on opioid prescribing practices to reduce OUDs and overdoses
Expand use of naloxone
Expand use of medication-assisted treatment (MAT), to reduce OUDs and overdoses

In addition to citing data, the White Paper highlights factors involved in a woman’s path to opioid misuse, among them life experiences, biological and social influences, geography, and demographic characteristics.

Purpose. The White Paper was commissioned to educate enrolled participants in advance of a September 2016 HHS-OWH national meeting. The goal of the meeting was to prepare participants to understand the impact of the opioid epidemic on women, across age, race, geography, and income, and to issue a post-meeting report on possible solutions to some of the problems discussed in the White Paper.

Underlying Psychological Differences in Women Lead to Riskier Behavior

Why do women behave differently from men when it comes to opioids? Psychological differences, such as women’s more intense opioid cravings, account for some of the riskier behavior. While both sexes are susceptible to psychological and emotional distress, a key difference exists: these distresses are actual risk factors for hazardous prescription opioid use in women, and only in women, studies show; men react to these distresses in other ways.

SAMHSA data (2015) reveal that 4% of females ages 12 and older misused prescription pain relievers during the previous year. Because misuse often leads to involvement of the health care system, it’s not surprising that, CDC data show, every three minutes another woman visits an emergency department because of prescription painkiller misuse.

Women with a substance use disorder are at increased risk of injection drug use, which can lead to viral hepatitis or to HIV. From 2010 to 2014, new cases of hepatitis C among women rose more than 260%—with substance use in part responsible. Younger women risk transmitting the infection to their infants—yet many, serving as caregivers and lacking childcare options, find it difficult to arrange for treatment for their disorder.

Preventing OUDs and Overdoses in Women

Few data exist on preventive measures for women, and studies tend to involve substances other than opioids. The tendency of women to quickly become physically dependent on opioids, mentioned earlier, involves several physiological differences that exist between men and women: metabolic rate, hormone levels, and percentages of body fat. With the risk of opioid-related harm higher in women, investigators see screening and early intervention as key steps in helping to protect women from OUDs and overdoses.

The HHS Opioid Initiative

Opioid Prescribing Practices

Between 2008 and 2012, more than one-third of Medicaid-enrolled women aged 18-44 and more than one-fourth of privately insured women in the same age group were prescribed opioids.

Expanding Naloxone Use in Women

Naloxone offers potentially life-saving treatment, but is under-used in women. A 2016 study found that men were almost three times more likely than women to be given naloxone in resuscitation efforts. With a nasal spray and an auto-injector formulation now available, perhaps more women who need naloxone will be able to obtain it.

The White Paper notes: “Given the trends in increased heroin use among women, increased availability and usage of naloxone may soon be that much more critical to prevent death from overdose among women.”

MAT for Women

Despite “overwhelmingly positive” evidence that MAT is effective, and a recommendation from the CDC that patients with an OUD be offered MAT, each year only 20% of adults—men and women—with an OUD receive MAT. The barriers: cost, access, and stigma.

Many women with an OUD lack the financial and child-care resources available to other women. Even those who can find affordable treatment and decide to enter a program may have problems arranging for child care.

Seeking Solutions

In response to the increasing impact of the opioid crisis on women, the HHS OWH held a national meeting on September 29-30, 2016. The meeting convened a national conversation on how best to address some of the problems described in the White Paper. AT Forum will check with HHS OWH later regarding its findings and recommendations, and, if appropriate, will publish a follow-up article.

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References

AAFP Supports Turn the Tide Rx Campaign to End Opioid Abuse. August 9, 2016. American Academy of Family Physicians Web site. http://www.aafp.org/news/health-of-the-public/20160809turntide.html. Accessed April 12, 2017.

Anson P. Post-Surgical Pain Guidelines Reduce Use of Opioids. Pain News Network Web site. February 18, 2016. https://www.painnewsnetwork.org/stories/2016/2/18/guidelines-for-post-surgical-pain-discourage-use-of-opioids. Accessed April 12, 2017.

CDC Vital Signs citing National Survey on Drug Use and Health 2002-2013. http://www.cdc.gov/vitalsigns/heroin/index.html#modalIdString_CDCImage_0. Accessed April 12, 2017.

Center for Substance Abuse Treatment. Chapter 13 – Medication-Assisted Treatment for Opioid Addiction During Pregnancy. In: Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.) http://www.ncbi.nlm.nih.gov/books/NBK64148/# 6.

Chou, R. et al. Management of Postoperative Pain: A Clinical Practice Guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. February 2016, Volume 17, Issue 2, Pages 131-157. http://www.jpain.org/article/S1526-5900%2815%2900995-5/fulltext#back-bib18. Accessed April 12, 2017.

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. doi: http://dx.doi.org/10.15585/mmwr.rr6501e1.

Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.

Significant Pain Increases the Risk of Opioid Addiction by 41 Percent

July 27, 2016

“What do we really know about the relationship between the experience of pain and risk of developing opioid use disorder? Results from a recent study – the first to directly address this question — show that people with moderate or more severe pain had a 41 percent higher risk of developing prescription opioid use disorders than those without, independent of other demographic and clinical factors.

These results, from researchers at Columbia University Medical Center, were published today in American Journal of Psychiatry.

The researchers analyzed data from a national survey of alcohol and substance use in more than 34,000 adults in two waves, three years apart. At each point, they examined pain (measured on a five-point scale of pain-related interference in daily activities), prescription opioid use disorders, and other variables such as age, gender, anxiety or mood disorders, and family history of drug, alcohol, and behavioral problems.

Participants who reported pain and those with prescription opioid use disorders were also more likely than others to report recent substance use, mood, or anxiety disorders or have a family history of alcohol use disorder.

“These findings indicate that adults who report moderate or more severe pain are at increased risk of becoming addicted to prescription opioids,” said Mark Olfson, MD, MPH, professor of psychiatry at Columbia University Medical Center, and senior author of the report. “In light of the national opioid abuse epidemic, these new results underscore the importance of developing effective, multimodal approaches to managing common painful medical conditions.”

Source: Eurekalert.org – July 22, 2016

Huffington Post Blog: How Nursing Is Helping to Combat the Opioid Epidemic

June 28, 2016

“In April, Deborah Trautman, PhD, RN, FAAN, President and Chief Executive Officer of the American Association of Colleges of Nursing (AACN), the national voice for baccalaureate and graduate nursing education, was asked to provide remarks to the White House Champions of Change for Prevention, Treatment, and Recovery event in Washington, D.C. Recently, I reached out to Dr. Trautman with a few questions in an attempt to garner her thoughts about the opioid epidemic and the role that nursing plays in addressing this nationwide crisis.” She addressed the following questions:

How do you see nursing education changing in the future due to this crisis?
How can consumers partner with their health care provider to address this nationwide problem?
In your opinion, what is the biggest myth about the opioid crisis?

She summarized, “the opioid crisis in the U.S. can only be averted through a collaborative effort of health care providers, consumers and community resources. The CDC offers Guideline Information for Patients to assist consumers with understanding the opioid crisis and to learn how they can partner with their provider to receive effective pain management.”

Source: HuffingtonPost.com – June 23, 2016

It’s Not Always About Getting High: People Often Abuse Prescription Drugs, Alcohol to Deal With Chronic Pain

May 25, 2016

“Far from chasing hedonistic highs, people who turn to drugs are often trying to stave away chronic bouts of pain, a study published this month in the Journal of General Internal Medicine suggests.

The authors analyzed survey data from around 25,000 patients who visited a primary care provider, ultimately focusing on 589 people who fit the criteria for drug abuse or illicit drug use. Of them, 87 percent reported chronic pain, with 74 percent adding that the pain interfered with their ability to function normally. And when asked outright, many of the patients admitted their drug use was an attempt to self-medicate the pain.

“While the association between chronic pain and drug addiction has been observed in prior studies, this study goes one step further to quantify how many of these patients are using these substances specifically to treat chronic pain,” said lead author Dr. Daniel Alford, an associate professor of medicine at Boston University, in a statement. “It also measures the prevalence of chronic pain in patients who screen positive for illegal drug use and prescription drug abuse.”

Source: MedicalDaily.com – May 9, 2016

Almost All Doctors Routinely Overprescribe Pain Pills: Survey

April 5, 2016

Pharmacist “Ninety-nine percent of primary care doctors routinely prescribe potentially addictive opioid painkillers for longer than the three-day period recommended by the Centers for Disease Control and Prevention, according to survey results released Thursday by the National Safety Council.

The Itasca-based nonprofit also found that doctors routinely prescribe the drugs for unsuitable conditions, such as lower back and dental pain, and that they often overlook nonaddictive medications some research has shown to be more effective.

“Studies have shown that once we get beyond seven days of these opiate prescriptions for acute pain, the outcomes become much worse,” said Dr. Donald Teater, the group’s medical adviser. ” … They get on these for a long time and have a hard time getting off them.”

Source: ChicagoTribune.com – March 24, 2016

Federal Officials, Advocates Both Want to Require Doctors to Use Pill-Tracking Databases to Curb Painkiller Abuse

April 5, 2016

“The nation’s top health officials are stepping up calls to require doctors to log in to pill-tracking databases before prescribing painkillers and other high-risk drugs.

The move is part of a multi-pronged strategy by the Obama administration to tame an epidemic of abuse and death tied to opioid painkillers like Vicodin and OxyContin. But physician groups see the proposed requirement to check the databases as overly burdensome, another time-consuming task that takes away from patient care.

Helping push the administration’s effort forward is an unusual, multi-million dollar lobbying campaign funded by a former corporate executive who has turned his attention to fighting addiction.”

Source: USNews.com – March 29, 2016

FDA Announces Enhanced Warnings for Immediate-Release Opioid Pain Medications Related to Risks Of Misuse, Abuse, Addiction, Overdose and Death

March 25, 2016

“In a continuing effort to educate prescribers and patients about the potential risks related to opioid use, the U.S. Food and Drug Administration today announced required class-wide safety labeling changes for immediate-release (IR) opioid pain medications. Among the changes, the FDA is requiring a new boxed warning about the serious risks of misuse, abuse, addiction, overdose and death. Today’s actions are among a number of steps the agency recently outlined in a plan to reassess its approach to opioid medications. The plan is focused on policies aimed at reversing the epidemic, while still providing patients in pain access to effective relief.

The FDA is also requiring several additional safety labeling changes across all prescription opioid products to include additional information on the risk of these medications. This is part of the agency’s overall effort to help inform prescribers about the importance of balancing the serious risks of opioids with their role in managing pain.”

Source: Federal Drug Administration – March 22, 2016

Researchers Show Rising Opioid Prescriptions Following Low-Risk Surgeries

March 25, 2016

“Physicians are prescribing more opioid painkillers than ever before to patients undergoing common surgeries, according to new research from the department of Anesthesiology and Critical Care at the Perelman School of Medicine at the University of Pennsylvania. Their work is published online this week in JAMA simultaneously with a major new guideline from the Centers for Disease Control and Prevention (CDC) that calls on physicians to avoid over-prescription of opioids for surgical patients and other patients with painful conditions.

The new study, which included researchers from the University of Toronto, analyzed insurance claims from 2004 through 2012 for 155,297 adults undergoing four common outpatient surgeries—carpal tunnel repair, laparoscopic gall bladder removal, some minimally invasive knee surgeries, and hernia repair. In an analysis of patients who had not received an opioid prescription in the six months preceding surgery, the researchers observed that four out of every five patients in the study filled a prescription for an opioid pain medication within the seven days after surgery. The percentage of patients who got those drugs increased over for the period studied all four surgical procedures.”

Source: MedicalExpress.com – March 18, 2016

Americans Have Been Addicted to Prescription Opiates Forever

March 17, 2016

“OPIATES ARE AMAZING. They make dentistry not a horror movie, make a broken bone something you can tolerate while waiting in the ER, and kept your great-grandpop from going into shock after being shelled in the trenches of Ypres. Opiates are also amazingly addictive. The government estimates that roughly 1.9 million Americans were hooked on opiates in 2013. Use and abuse in America has reached epidemic levels, prompting the Centers for Disease Control and Prevention to issue a new set of recommendations from the CDC to control how doctors are distributing the drugs.

The recommendations came out yesterday (see related article below), but this problem isn’t new: Opiates have always oscillated between medicine and drug. Their regulatory history reflects the precarious balancing act between help and harm—one that the CDC’s new recommendations will address, but never solve.”

Source: Wired.com – March 16, 2016