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Progressive Opioid Use: Who’s At Risk?

Progressive Opioid Use: Who’s At Risk?

Throughout the United States, greater attention is being paid to accidental overdoses from the long-term use of opioids. Experts have reported that there is an urgent need to better understand patterns of opioid prescribing. In most cases, healthcare providers do not prescribe opioids with the intent of having patients use them long term, nor do they intend to provide repeat prescriptions. “Opioids are an important drug class that is used to manage short-term pain as well as pain after surgical procedures or trauma,” explains W. Michael Hooten, MD. “At the same time, it’s critical that these medications are prescribed carefully to ensure their safe use by patients.” Studies are lacking on the characteristics associated with the transition from shorter-term to longer-term opioid use, says Dr. Hooten. “When opioids are first prescribed, it’s unclear which patients are more likely to eventually receive repeat prescriptions,” he says. “A better understanding of these characteristics may help guide efforts to optimize opioid use. It could also help us anticipate the potential for inappropriate episodic or long-term use.” Exploring Recent Trends The Consortium to Study Opioid Risks and Trends (CONSORT) is an initiative supported by the National Institute of Drug Abuse that has identified trends and risks associated with long-term opioid therapy for chronic pain. CONSORT classified opioid prescribing patterns as 1) short-term use, 2) episodic use, and 3) long-term use. Dr. Hooten and colleagues had a study published in Mayo Clinic Proceedings that sought to determine how often patients receiving new opioid prescriptions progressed to episodic or long-term opioid use. It also examined associations between patient characteristics and the transition to longer-term use...

Drug Wars in the Exam Room

As physicians, we have all been faced with patients inappropriately looking for prescriptions for controlled substances. Some are looking to abuse them and some to divert them for profit. It is often hard to distinguish when a patient truly needs these medications or when they are just “drug-seeking.” More experienced doctors have a better sense of which patients are which. Drug-seeking patients often play on our emotions because they know we generally care about patients and may have difficulty turning down a request for opioids from someone in supposed pain. For years, patients have used many ruses to access these medications. Many of them “doctor shop,” use several pharmacies, or frequent various emergency rooms, making it difficult to track their prescriptions. And it’s much harder for a doctor to turn down a request from a new patient in acute pain than from one the doctor knows well and doubts. Having so many controlled substances available and sold on the streets has led to an increase in prescription drug dependency. These patients have a hard time breaking these addictions and often can only stop with help from special rehab programs. It has led to a further resurgence of IV heroin addiction and opioid deaths in many areas. As the states have tightened controlled substance prescriptions, they have become less available for diversion and are now a gateway drug to heroin—which is cheaper than prescribed medications. I am seeing teens in my practice addicted to IV heroin, a habit that started by raiding parents’ or relatives’ medicine cabinets. It has never been more imperative for doctors to step up and do...
Examining Physician Rx Drug Abuse

Examining Physician Rx Drug Abuse

Substance use is one of the most frequent causes of impairment among physicians, and some reports estimate that 10% to 15% of doctors will have a substance use disorder in their lifetime. “Substance-related impairment among physicians is a serious problem, with significant consequences for patient safety and public health,” says Lisa J. Merlo, PhD, MPE. “The rate of physician substance use is similar to that of the general population, but physicians are more likely to misuse prescription drugs. Understanding the reasons for prescription drug misuse may help us more successfully identify, treat, and monitor addicted physicians.” A key challenge to treating substance use disorders is that most physicians do not refer themselves for treatment, making it difficult to collect data on this issue. One strategy is to partner with physician health programs (PHPs) to recruit study participants. PHPs were established to ensure that distressed or impaired physicians are treated and monitored for the long term so that they can safely return to practice. “Studies have shown that nearly 80% of physicians who participate in PHPs remain substance free—with no relapse—at 5 years follow-up,” Dr. Merlo says. “Unfortunately, many doctors with substance use disorders have these problems for years before they seek help or are referred to a PHP.” Exploring the Issue Despite the impact of substance use among physicians, few analyses have looked at prescription drug misuse in this population. Studies have suggested that access to prescription medications may increase the risk of substance abuse among physicians. However, Dr. Merlo says that more information is needed to understand the reasons for prescription drug misuse among physicians and to develop...
Understanding Cannabinoid Designer Drugs

Understanding Cannabinoid Designer Drugs

Over the last few years, research has shown that abuse of synthetic drugs is becoming more common throughout the country. In response to this, the United States Drug Enforcement Agency has listed an increasing number of synthetic cannabinoids (SC) as Schedule 1 substances, and Congress has passed the Synthetic Drug Abuse Prevention Act. “SC products have received substantial media attention for being sold as legal highs,” explains Patrick M. Lank, MD. Common SCs include “Spice” and “K2,” and these drugs are often packaged as incense. Tough Spot for EDs Complications from SC use have led to an increase in hospital visits, particularly for EDs. “The initial growth of SC use in the U.S. was sparked by reports that they had effects similar to marijuana,” says Dr. Lank. “An added advantage was that they were thought to be undetectable on routine urine drug screens and were widely available by legal public consumer means. We have learned over time that the clinical effects of SCs are quite different from those caused by smoking marijuana.” There is growing concern for the potential of long-term immunologic, neurologic, and psychiatric complications with SC use, specifically in adolescents. Dr. Lank says emergency physicians (EPs) are in a particularly difficult position as the use of new synthetic drugs increases in popularity. “EPs often must treat patients who abuse SCs despite having relatively little knowledge of these substances,” he says. “Considering the increasing popularity of SCs, it’s important to assess EP knowledge of these designer drugs and explore ways to optimize care for patients presenting to EDs after exposure to these drugs.” New Data & Insights In...
Opioid Backlash Threatens Sickle Cell Care

Opioid Backlash Threatens Sickle Cell Care

The well-meaning push to curb opioid prescribing could worsen healthcare for sickle cell patients. Clinicians tend to undertreat the substantial pain experienced by many sickle cell patients and treat them as drug addicts. However, research does not support increased risk of addiction in this patient population. Challenging Pain, Few Options A 2008 study in Annals of Internal Medicine revealed a vast undercurrent of chronic pain in sickle cell disease, with 29% of patients reporting pain—which is often severe—nearly every day. On top of that, vaso-occlusive episodes can trigger excruciating pain and life-threatening complications, such as organ damage. These crises prompt most ED visits for sickle cell disease. Hydroxyurea, the one drug approved by the FDA to treat the disease, is used infrequently despite being effective. The drug lessens the frequency of pain crises but does not eliminate them. In any case, opioids remain essential for treating sickle cell pain. Clinical trials testing these agents in sickle cell populations are lacking, but even less is known about possible alternatives. Inaccurate Assumptions of Pain A recent study found that most sickle cell patients delay seeking treatment until their pain nears 9 on a 10-point intensity scale. When they finally go to the ED, they face longer waits for care than others in less pain. In some research, these patients report that healthcare providers sometimes treat them without respect. Indeed, clinicians often wrongly suspect them of exaggerating their pain or abusing drugs. A Patient-Centered Approach to Treating Sickle Cell Pain Treating sickle cell pain starts with assessment, but no laboratory test or physiological marker can measure this pain. Nor can clinicians gauge...
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