Tips for healthcare providers who prescribe opioid painkillers
Doctors like you can make a big difference in the prescription opioid overdose epidemic currently scourging the U.S. Any patient you see could potentially be a dope fiend – enslaved to both illicit opioids like heroin and prescription painkillers like oxycodone, hydrocodone, fentanyl and methadone. Of course, you can’t just accuse everybody of being a junkie, nor can you ignore the warning signs when and if you see them. The Substance Abuse and Mental Health Services Administration (SAMHSA)’s opioid overdose toolkit provides advice on how to identify and address opioid addiction.
Assessing the patient
Obtain a history of the patient’s previous use of illicit and/or prescription drugs asking such questions as:
· Have you taken any medications to help you calm down, keep from getting nervous or upset, raise your spirits, make you feel better, and the like, in the past 6 months?
· Have you been taking any medications or abusing alcohol to help you sleep?
· Have you ever taken a medication to help you with a drug or alcohol problem?
· Have you ever taken a medication for a nervous stomach?”
· Have you taken a medication to give you more energy or to cut down on your appetite?”
· Have you ever been treated for a possible or suspected opioid overdose?
Precautions for new patients
Many experts recommend that physicians take special precautions when prescribing for new patients, to wit:
· Assessment. Patient history and examination, medications that have been prescribed and for what indications, and what substances (including alcohol, illicit drugs and OTC products) the patient has reported using, when and what amount was last used and by what route. Medical records should be obtained with the patient’s consent.
· Emergencies. The smallest possible quantity, typically not exceeding a supply for three days, should be prescribed in emergency cases. A return visit should be arranged for the following day. Consider prescribing naloxone to help lower the risk associated with these emergent situations. At the very least, the patient’s identity should be verified by asking for proper identification.
· Limited quantities. Prescribe only enough of an opioid analgesic to meet the patient’s needs until the next appointment in non-emergency situations. You should have the patient return for further prescriptions, since telephone orders are not ideal for a proper reassessment of the patient’s condition.
Selecting the appropriate medication
The effectiveness and safety of all potentially useful drugs should be reviewed for their relevance to the patient’s condition. The dose, schedule, and formulation should be established once an appropriate medication has been selected.
· Dose. Based on the age and weight of the patient as well as the severity of the condition, possible loading-dose requirement, and the presence of drugs with potential interactions.
· Timing of administration. For example, bedtime dose to decrease problems related to sedative or respiratory depressant effects.
· Route of administration. Chosen to maximize compliance/adherence and to achieve peak drug concentrations quickly.
· Formulation. For instance, selecting a patch over a tablet, or an extended release medication instead of an immediate release formula.
You should also consider three more factors before prescribing an opioid painkiller:
1. The severity of symptoms and the patient’s ability to accommodate them. Relieving symptoms is a legitimate goal, but opioid painkillers should be used with caution.
2. The patient’s reliability in taking medications, as determined through observation and history-taking. You should assess the patient’s history of, and risk factors for, drug abuse – and weigh the benefits against the risks – prior to prescribing psychoactive drugs. Use periodic check-ups to monitor the likely development of physical dependence in patients on long-term opioid therapy.
3. The medication’s potential for producing dependence. You should consider whether a potentially less addictive product or a drug-free therapy – such as electrotherapy with TENS units – would be equally beneficial. Warn your patients about opioids’ possible side effects and interactions with other drugs and substances like alcohol. Inform your patients that it is illegal to sell, give away, or share medications with other people. Instruct your patients to store medication in a locked cabinet and to dispose of unused supplies safely.
Educating the patient and getting informed consent
You must inform your patient about the risks and benefits of the proposed therapy as well as the ethical and legal implications that the said therapy imposes on the patient and on yourself, in order to obtain informed consent. This consent can do the following things:
· Provides the patient with information about the risks and benefits of opioid treatment.
· Promotes adherence to the therapy.
· Limits the potential for unintentional misuse of drugs.
· Enhances the effectiveness of the program
Patient education and informed consent should address the following:
The potential for physical dependence and cognitive impairment as side effects of opioid painkillers
Instruct the patient to stop any and all other pain medications, unless explicitly told to continue by the physician – i.e., you – thus reinforcing the need to adhere to a single treatment program.
· The patient’s agreement to obtain the prescribed medication only from you, and if possible, from a single designated pharmacy.
· The patient’s agreement to take the medication only as prescribed.
· The patient’s responsibility for safeguarding the written prescription and the supply of medications, arranging refills during regular office hours, and planning ahead so as not to run out of medication during weekends or vacation.
· The consequences for not adhering to the treatment plan, including discontinuation of opioid therapy if the patient's actions compromise his or her safety.
The informed consent must be signed by doctor and patient, with a copy kept in the latter’s medical record. Consider giving another copy to the patient or providing a laminated card identifying the person as your patient in order to justify his or her possession of controlled drugs.
Executing the prescription order
Do this carefully to avoid manipulation by the patient or others intent on obtaining opioids for non-medical purposes. Federal laws mandate that all prescription orders include the following:
· Signature of the physician.
· Date of the day they were issued.
· Name and address of the patient.
· Name, address, and DEA registration number of the physician.
· Name and quantity of the prescribed drug.
· Directions for use.
· Refill information.
· Effective date if other than the date on which the prescription was written.
Additional requirements may be imposed depending on the state (consult the state medical licensing board). Keep blank prescription pads under lock and key, and report the theft or loss of prescription blanks to the nearest field office of the federal Drug Enforcement Administration and to the state board of medicine or pharmacy, to avoid the forgery of prescriptions.
Monitoring the patient’s response to therapy
Document and communicate to the patient your plans to monitor for drug efficacy and safety, compliance, and potential development of tolerance. Subjective symptoms and objective clinical signs are important for monitoring. Ask the patient to keep a log of signs and symptoms so as to provide them with a sense of participation and to facilitate your review of therapeutic progress and side effects.
Prescribing naloxone with the initial opioid prescription
Naloxone is an antidote for opioid overdose. Properly educated patients on long-term opioid therapy may benefit from a naloxone kit with syringes and needles, or a single dose delivered with an auto-injector. Requisites for a naloxone kit include:
· Taking high doses of opioids for long-term treatment of chronic malignant or non-malignant pain.
· Receiving rotating opioid medication regimens.
· Having been discharged from emergency medical care after opioid intoxication or poisoning.
· Being at high risk of overdose due to legitimate medical need for analgesia, along with a suspected or confirmed history of substance abuse, dependence, or non-medical use of prescription or illicit opioids.
· Being on certain preparations that may increase the risk for opioid overdose (e.g., extended release/long-acting preparations).
· Completing mandatory opioid detoxification or abstinence programs.
· Having been recently released from incarceration and being a past user and abuser of opioids.
Prescribing naloxone to manage opioid overdose is consistent with the drug’s FDA-approved indication. No increased liability should result provided the prescriber meets general rules of professional conduct. Most states prohibit doctors from prescribing naloxone to a caregiver or another third party.
When to end therapy
Situations that warrant immediate cessation of therapy include:
· Altering or selling prescriptions.
· Accidental or intentional overdose.
· Multiple episodes of running out early because of excessive use.
· Doctor shopping.
· Engaging in threatening behavior.
The steps to follow in such situations are:
1. Stop prescribing.
2. Tell the patient that continued prescribing is not clinically supportable.
3. Encourage the patient to accept a referral for assessment by an addiction specialist.
4. Educate the patient on the signs and symptoms of spontaneous withdrawal and urge them to visit the emergency department should withdrawal symptoms occur.
5. Retrain on the risks and the signs of opioid overdose and on the use of naloxone and consider prescribing naloxone if considered appropriate.
6. Reassure the patient that he/she will continue to receive care for the presenting symptoms or condition.
Treating opioid overdose
Signs of overmedication (may precede overdose)
· Unusual sleepiness, drowsiness, difficulty staying awake in spite of low verbal stimulus or vigorous external rub, or difficulty waking them from sleep.
· Mental confusion, slurred speech, intoxicated behavior.
· Slow or shallow breathing.
· Small pupils (normal-sized pupils do not preclude overdose).
· Slow heartbeat.
· Low blood pressure.
Signs of overdose
· Extreme sleepiness.
· Inability to awaken verbally or with external rub.
· Respiratory problems ranging from slow to shallow breathing in a patient that cannot be awakened.
· Blue/purple fingernails or lips.
· Extremely small pupils.
· Slow heartbeat.
· Low blood pressure.
· Make sure the airway is clear.
· Tilt the head back with one hand on the patient’s chin, and pinch the nose closed.
· Put your mouth over the patient’s mouth to make a seal and give two slow breaths – the patient’s chest, but not the stomach, should rise.
· Repeat with one breath every 5 seconds.
· Intravenous administration provides the quickest onset o faction, and is recommended in cases of emergency.
· The intramuscular or subcutaneous route may suit patients with a history of opioid dependence better because of its slower onset of action and long-lasting effect which minimize rapid onset of withdrawal symptoms.
· The lowest dose of naloxone to maintain spontaneous respiratory drive may be used safely in pregnant women.
· Most patients respond by returning to spontaneous breathing with mild withdrawal symptoms.
· Response generally occurs within 3-5 minutes of administration (rescue breathing should continue while waiting for naloxone to take effect).
· Duration of effect is 30-90 minutes depending on dose and route of administration.
· Patients should be observed for at least 4 hours after the dose of naloxone for reemergence of overdose symptoms.
· The goal of naloxone therapy should be restoration of adequate spontaneous breathing, but not necessarily complete arousal.
· More than one dose may be required to revive the patient.
· Even if revived, the patient should be taken to an emergency department or other source of acute care as quickly as possible.
Signs of opioid withdrawal triggered by naloxone
· Body aches.
· Runny nose.
· Piloerection (goose bumps).
· Nausea or vomiting.
· Nervousness, restlessness or irritability.
· Shivering or trembling.
· Abdominal cramps.
· Increased blood pressure.