One can hardly open the paper, read the internet, or listen to the news without a story about the "opiod epidemic" Mississippi may not be the epicenter of this epidemic but we are in the top teir of states with an opiate problem. Our problem is not the heroin epidemic that exists in New Hampshire but we do utilize a large amount of other opiates (and our heroin usage is growing daily). Since most of the prescription opiates on the street are either prescribed to the user or diverted from what was thought to be a ligitiment prescription, intervention would naturally start with the prescribers. To facilitate in this transformation, the Centers for Disease Control published a set of guidelines in March of 2016. The interested reader may access these guidelines in their entirety at the CDC website. The specific web address is https://www.cdc.gov/mmwr/65/rr/rr6501e1.htm. At the end of this article, I have replicated the 12 items discussed in the guidelines.
Before we delve into the guidelines let us take a moment to define the substances about which we are discussing. Opiates or narcotics are a group of chemicals naturally derived from the opium poppy. The resin from the poppy gives rise to an opiate compound that may be further refined into various pharmaceutical opioid compounds such as morphine and codiene as well as the street drug heroin. These are found in certain prescription cough syrups as well as the hydorcodone-acetominophen compounds that go by such names as Tylenol #3 and 4 and Norco 3, 4, 7.5, and 10. The numeral denotes the milligrams of codiene in each tablet. Perhaps the most sought after opiate is the semi-synthetic opiate oxycodone. This is a potent, longer acting opiate that accounts for many opiate overdoses. Oxycodone can be found in medication such as Percocet. The most potent opiate on the US market is Fentanyl. This is usually prescribed as patch that is applied every three days and releases a set amount of fentanyl per hour. Fentanyl is measured in micrograms (the other opiates are measured in milligrams). This makes fentanyl a 1000 times more potent on a weight basis than the other opiates. The only indication for Fentanyl is cancer pain and certain anesthesia settings where immediate respiratory support is available and a physician is attending. The fentanyl being mixed with heroin on the street is generally not derived from breaking apart fentanyl patches or crushing lollipops (yes, they do make these) but is rather a pro-drug that is imported from China to the US (this gets around the drug laws) and then refined in a US laboratory to yield fentanyl. The compound carfentanyl is a large animal tranquilizer that is deadly to humans in just about any dose--a single drop of the pure compound on the skin may be deadly.
Used by themselves, in limited dosage, and for short periods of time these compounds are of great therapeutic benifit. However, over a relatively short period of time the patient becomes tolerant to the analgesic and feeling of well being effect but not the respiratory depressive effect. This is when mixtures with other compounds, especially benzodiazapines, may become deadly. Benzodiazapine is a chemical class designation for a group of sedative hypnotic agents. The sedative hypnotics also contain other chemical agents with similar properties. These include the "sleeping pills" as well as the anticonvulsant phenobarbital. Common benzodiazapines include Xanax, Valium, Klonopin, Tranxene, Librium, among others. The "sleeping pills" include such common agents as Abiem, Sonata, Halcion, Restoril, and Lunesta. All of these agents have three clinical properties that vary in intensity by compound: sedation, amnesia, and anti-anxiety. Only phenobarbital, as a sole agent, significantly impairs respiratory drive. However, when a benzodaizapine is combined with an opiate, even after years of using these together, the respiratory drive may be impaired to the point it may lead to death. With this as background, now let us turn to the guidelines as promulgated by the CDC.
1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.
2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do no outweigh risks. Clinicians should continue opiod therapy only if there is clinically meaningful improvement in poin and function that outweighs risks to patient safety.
3. Before starting and peiodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinicain responsibilities for managing therapy.
4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids.
5. When opioids are started, clinicians should prescribe the lowest effective dosage.
6. Long-term opioid use often begins with treatment of acute pain.
7. Clinicians should evaluate benefits and harms with patients within 1-4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently.
8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms.
9. Clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other ontrolled prescription drugs and illicit drugs.
11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
12. Clincians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
I hope the posting of these guidelines are of help to those of you who are prescribed opiates or have a relative who is prescribed opiates. These guidelines concern the use of opiates for chronic pain, not acute pain. Acute pain is that associated with such things as a broken bone, surgery or other trauma that is expected to diminish or abate after a few days. Opiates are indispensable for these conditions. However, pain lasting more than a few days to weeks or months is considered chronic pain and alternate agents and therapies are often used for this. In additon to me taking these guidelines seriously, the Mississippi State Board of Medical Lisencure and the State Bureau of Narcotics also take these guidelines seriously. Please remember that the above agencies (as well as other state boards and all law enforcement agencies) have unfettered access to your PDMP and are not a "covered entity" under the health care privacy act (HIPPA) as am I.