Stacey Pascoe, PharmD, BCPP, CPP

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Program Outline

  • Review of Pain
    • Opioid Pain Medications
    • How they work
    • Appropriate use
    • Adverse effects and other risks
  • Treatment of acute opioid overdose
  • Drug interactions with opioids
  • Other potentially inappropriate medications

The Significance of Pain…

“No experience rivals pain for its ability to capture our attention, focus our actions, and cause suffering”

Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved January 31, 2021 fromhttps://stahlonline.cambridge.org/essential_4th.

Pain as a Protective Mechanism

  • Pain has a function
    • Protects your from harm or further harm 
    • Can be strong, potent process that generates an IMMEDIATE response
    • Can be gradual, persistent process indicating damage OVER TIME
  • Peripheral system: outside the brain 
  • Central system: inside the brain
    • Discriminatory: what type of pain am I experiencing? 
    • Emotional: lasting record of how pain felt
  • Chronic pain with moderate-to-severe intensity affects about 30% of geriatric patients (≥65 years old)
Daubresse M, Chang HY, Yu Y et al. Ambulatory diagnosis and treatment of nonmalignantpain in the United States, 2000–2010. Med Care. 2013; 51:870-8.

List of Prescription Opioids

  • Codeine
  • Fentanyl (Duragesic) 
  • Hydrocodone (Hysingla, Zohydro ER) 
  • Hydrocodone/acetaminophen (Lortab, Norco, Vicodin)
  • Hydromorphone (Dilaudid)
  • Meperidine (Demerol)
  • Methadone (Dolophine, Methadose) 
  • Morphine (Kadian, MS Contin)
  • Oxycodone (OxyContin, Oxaydo)
Oxycodone/acetaminophen (Percocet, Roxicet) Opioid (Narcotic) Pain Medications. WebMD. https://www.webmd.com/pain-management/guide/narcotic-pain-medications#1. Accessed: January 7, 2021.

How Opioids Work 

  • Opioid receptor system is complex
  • The body naturally produces chemicals that interact with this system 
  • Opioid receptors are located inside and outside the brain
    • adrenal glands, gastrointestinal tract, heart, pancreas, many organ tissues
  • One function: change the perception of peripheral pain so you can get out of danger 
    • Example: Able to run away from a bear with a broken ankle
    • This is meant to be a brief, rapid process 
  • Another function: changes emotional response to pain
Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved January 31, 2021 fromhttps://stahlonline.cambridge.org/essential_4th. Shenoy SS, Lui F. Biochemistry, Endogenous Opioids. 2020 Jul 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 30422494.

Why are we so concerned about opioids? 

  • Opioids involved in more than 67% of all drug overdose deaths 
  • Margin for error is relatively small
  • Consequence of error is severe 
    • Overdose and errors can be fatal 
  • Chronic use does not result in better management of pain or better outcomes Boyer EW. Management of opioid analgesic overdose.
N Engl J Med. 2012; 367:146-55. Shenoy SS, Lui F. Biochemistry, Endogenous Opioids. 2020 Jul 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 30422494.

Opioids Adverse Reactions 

  • Drowsiness 
  • Headache 
  • Dizziness 
  • Confusion 
  • Irritability 
  • Insomnia 
  • Fatigue 
  • Depression
  • Flushing/Itching 
  • Sweating 
  • Dry mouth 
  • Urinary retention 
  • Decreased blood oxygen 
  • Shortness of breath 
  • Cough
  • Weakness 
  • Tremor 
  • Blurred vision 
  • Nausea 
  • Constipation 
  • Vomiting 
  • Decreased appetite
Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved January 31, 2021 fromhttps://stahlonline.cambridge.org/essential_4th.

Another problem with opioids.

  • Tolerance: more of the medication is required to produce the same effect 
  • Dependence: a state of needing something or someone, esp. in order to continue existing or operating 
  • Withdrawal: physical and mental effects experienced after stopping or reducing intake of a substance
Shenoy SS, Lui F. Biochemistry, Endogenous Opioids. 2020 Jul 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 30422494. Cambridge Academic Content Dictionary. Cambridge University Press. https://dictionary.cambridge.org/us/dictionary/english/dependence. Accessed January 23, 2021.

Substance/Opioid Use Disorder: yes or no?

1. Taking larger amounts or for longer period than intended

2. Persistent desire or unsuccessful efforts to cut down or stop

3. A great deal of time is spent in obtaining/using/recovering

4. Craving, or a strong desire or urge to use

5. Failure to fulfill major obligations at work, school, or home

6. Continued use despite problems (social or interpersonal)

7. Social, occupational, or recreational activities are given up or reduced

8. Recurrent use in situations in which it is physically hazardous

9. Continued use despite knowledge of having a problem

10. Tolerance: increased amount to achieve desired effect or diminished effect with same amount

11. Withdrawal: occurrence of symptoms or using another substance to avoid withdrawal

2-3 = mild

4-5 = moderate

≥6 = severe

 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM 5). Washington, DC: American Psychiatric Association; 2013.

Ways to Stop Opioids 

  • Gradual taper off until medication discontinued 
  • Slow process, minimize withdrawal symptoms 
  • “Cold turkey” 
  • Non-fatal, quiet unpleasant 
  • Augment with medication treatment for symptoms of withdrawal 
  • Used briefly while opioids leave the body and the body adjusts 
  • Typically taken orally multiple times per day 
  • Medication treatment for long-term “replacement” 
  • Used for maintenance of abstinence from abuse/misuse
  • Option for oral medications: daily or twice daily, or 
  • Some long-acting options: monthly injection or 6-month implant
Substance Abuse and Mental Health Services Administration (SAMSHA). Medications for opioid use disorder: for healthcare and addiction professionals, policymakers, patients, and families. Treatment improvement Protocol (TIP) Series 63, Full Document. HHS Publication No. (SMA) 19-5063FULLDOC. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. https://www.ncbi.nlm.nih.gov/books/NBK535268/. Accessed October 14, 2019

Opioid Withdrawal: ACUTE WITHDRAWAL is non-fatal and will start within hours of missed dose:

Opiate Withdrawal Timeline

  • Start:  Take your last dose
  • 72 Hours:  Physical symptoms at peak (chills, fever, body aches, diarrhea, insomnia, muscle pain, nausea, dilated pupils)
  • 1 Week:  Physical symptoms start to lessen (tiredness, sweating, body aches, anxiety, irritablity, nausea) 
  • 2 Week:  Psychological and emtional symptoms (depression, anxiety, irritability, restlessness, trouble sleeping)
  • 1 Month:  Cravings and depression (symptoms can linger for weeks or months)
Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012; 367:146-55. "DrugFacts: Prescription Opioids." NIDA. May 2022. National Institute on Drug Abuse. https://www.drugabuse.gov/publications/drugfacts/prescription-opioids. Accessed January 15, 2020.

Signs Of An Opioid Overdose

Learn how to spt an overdose and what to do.

  • Cold or clammy skin
  • Pupils extremely small
  • Discolouration of lips and nails
  • Dizziness and disorientation
  • Breathing slow or absent
  • Cannot be woken up or not moving

CALL 911 IMMEDIATELY!

Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012; 367:146-55.

Groups at Higher Risk of Overdose 

  • Those using more potent opioids (fentanyl, hydromorphone, etc.) 
  • Non-oral administration route
  • Using more than 50 mg/day (morphine equivalent) 
  • Treatment longer than 90 days 
  • Long-acting opioid in treatment naïve patient 
  • Long-acting opioid in combination with short-acting opioid 
  • Rural residence 
  • Comorbid anxiety, depression, alcohol use 
  • Obtaining prescriptions from multiple doctors and pharmacies
Norton, Merrill; Baldwin, Jeffrey N; O’Neil, Michael G; et al. The pharmacists’ guide to opioid use disorders. American Society of Health-System Pharmacists. Bethesda, MD [2018].

CDC Recommendations 

  • Opioids should not be “first-line” 
  • Establish goals for pain and function
  • Prescribe lowest dose, shortest course 
  • Evaluate benefits versus harm frequently 
  • Mitigate risk: offer naloxone 
    • ≥50 mg morphine equivalent/day 
    • History of overdose 
    • History of substance use disorder 
    • Concurrent use of “CNS depressants” 
  • Offer options for treatment

More than 40 people die every day from overdoses involving prescription opioids.

4.3 million Americans engaged in non-medical use of prescription opioids in the last month

Learn more visit www.cdc.gov/drugoverdose/prescribing/guideline.html

Treatment of Opioid Overdose

  • Call for help! 
    • When seeking help at home – call 911 
  • Check for pulse and breathing 
    • If none – begin CPR if you are able 
  • Give naloxone 
    • If lay person at home – nasal route or intramuscular available 
    • If homecare medical professional or in a facility – follow protocol
    • The patient will NOT be harmed if naloxone is used outside of opioid overdose
Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012; 367:146-55.

Using Naloxone at Home 

Montana Standing Order For Naloxone Opioid Antagonist (Update 2020)

 

  • Available at pharmacies in Montana without a prescription and insurance can be billed
  • Nasal spray: 
    • Most affordable 
    • Cost for 2-pack is $100-150 without insurance 
  • Intramuscular “auto-injector”: 
    • Brand name cost for 2-pack is >$4,000 
    • Generic now available, cost <$200 
  • Give first dose: as soon as possible 
  • SEEK MEDICAL CARE – DO NOT WAIT FOR RESPONSE 
  • Second dose: 2-3 minutes after first dose if no or minimal response 
  • Store at room temperature
Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012; 367:146-55.

Using Naloxone at Home: What to Expect 

Most opioid overdoses happen at home. Naloxone stops an overdose and saves lives.

  • Response will be fast 
    • Auto-injector: 2-5 minutes 
    • Nasal: 8-13 minutes 
  • Withdrawal from opioids will be severe 
    • Pain will come back! 
    • Remember: opioid withdrawal is unpleasant but NOT fatal 
  • Overdose symptoms may recur 
    • Naloxone lasts 30-120 minutes 
    • Most opioids last much longer
Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012; 367:146-55.

Practical Issues with Opioids in Homecare 

  • Prescription refills 
    • Need new RX each time 
    • No early refills 
  • Sticking to dosing schedule and tolerating pain 
    • Will need more medication over time to have same effect due to tolerance 
    • Can result in frequently “negotiation” with patient 
  • Working with an individual who is in pain 
    • Opioids and pain can worsen depression
Norton, Merrill; Baldwin, Jeffrey N; O’Neil, Michael G; et al. The pharmacists’ guide to opioid use disorders. American Society of Health-System Pharmacists. Bethesda, MD [2018].

Red Flags for Diversion 

  • Multiple allergies to common, less potent opioids 
  • Multiple reports of theft/loss of prescriptions 
  • Paying cash ONLY for controlled substances 
  • Multiple providers 
  • Multiple pharmacies 
  • Strong reaction to suggestion of med changes (patient, family member, caregiver, etc) 
  • Quickly escalating behaviors when requests are not met 
  • Failure to show response to traditional opioid doses 
  • Significant alterations in mental status following visits of family or friends 
  • Persistent and excessive complaints of pain in spite of aggressive treatment
Norton, Merrill; Baldwin, Jeffrey N; O’Neil, Michael G; et al. The pharmacists’ guide to opioid use disorders. American Society of Health-System Pharmacists. Bethesda, MD [2018].

Common Drug Interactions with Opioids

“Opioid overdose deaths and emergency department visits for nonfatal drug overdoses occur more frequently when they are combined with other central nervous system (CNS) depressants such as alcohol or benzodiazepines risks of additive respiratory depression and sedation, this combination of medications can be lethal for patients”

Norton, Merrill; Baldwin, Jeffrey N; O’Neil, Michael G; et al. The pharmacists’ guide to opioid use disorders. American Society of Health-System Pharmacists. Bethesda, MD [2018].

Drug Interactions with Opioids 

  • Alcohol 
  • Benzodiazepines - lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax) 
  • Muscle relaxers - methocarbamol (Robaxin), cyclobenzaprine (Flexeril), tizanidine (Zanaflex) 
  • Sleep medicines – zolpidem (Ambien), eszopiclone (Lunesta) 
  • Antihistamines – diphenhydramine (Benadryl), doxylamine (Unisom), meclizine (Antivert)
  • Medications used to treat restless legs – ropinirole (Requip), pramipexole (Mirapex) 
  • Medications that increase serotonin – antidepressants, etc
  • Other pain medications – gabapentin, Lyrica 
  • THC and CBD
Norton, Merrill; Baldwin, Jeffrey N; O’Neil, Michael G; et al. The pharmacists’ guide to opioid use disorders. American Society of Health-System Pharmacists. Bethesda, MD [2018]. 

Other Potentially Inappropriate Medications in the Elderly 

  • Older antihistamines (Benadryl, Unisom, meclizine) 
  • Gastrointestinal antispasmodics (belladonna, dicyclomine, hyoscyamine) 
  • Some hypertension and cardiac medications (doxazosin, clonidine, diuretics, digoxin) 
  • Tricyclic antidepressants (amitriptyline, nortriptyline, imipramine) 
  • Antipsychotic agents (Haldol, Zyprexa, Seroquel) 
  • Benzodiazepines (Ativan, Klonopin, Xanax) 
  • Sleep medications (Ambien, Lunesta) 
  • Some diabetes medications (risk of low blood sugar, dosing errors) 
  • NSAIDs (ibuprofen, naproxen, meloxicam) 
  • Muscle relaxers (Soma, Robaxin, Flexeril) 
  • Dietary supplements: stick to the mainstream and do your research
American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. doi: 10.1111/jgs.15767. Epub 2019 Jan 29. PMID: 30693946.

Questions?

Don’t hesitate to reach out: spascoe@bozemanhealth.org

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