Opioid-Related Disorders

Chronic use of opioids can result in suppression of the hypothalamic, pituitary, adrenal axis causing adrenal insufficiency in up to 15% of patients. James W. Mold, MD, MPH

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A woman in her 40s with opioid use disorder receiving methadone (70 mg daily) was admitted for extended antibiotic treatment for methicillin-resistant Staphylococcus aureus bacteremia. She had been taking methadone at varying doses (ranging from 15 to 70 mg daily) for 15 years.

Following the resolution of bacteremia, she experienced unexplained persistent hyponatremia (129 mEq/L) and dizziness, with her urine sodium levels exceeding 40 mEq/L. A high dose, 250-μg cosyntropin stimulation test was performed, which revealed her cortisol levels were 6.6, 17.2, and 19.2 μg/mL (to convert to nmol/L, multiply by 27.6) at baseline, 30 minutes, and 60 minutes, respectively. A serum adrenocorticotropic hormone (ACTH) level was not measured.

Author/s:

Douglas Rice, Hirofumi Yoshida

Responding to Unsafe Opioid Use: Abandon the Drug, Not the Patient

Devin Evans — Wed, 24 Mar 2021 05:00:00 +0000

Date Added:

March 24, 2021

Journal/Publication:

Journal of General Internal Medicine

Publication Date:

October 9, 2020

Issue:

Volume:

Pages:

790-791

URL:

Responding to Unsafe Opioid Use: Abandon the Drug, Not the Patient

Type:

Best Local Practices

Format:

Article

DOI (1):

10.1007/s11606-020-06281-4

Keywords

Opioid Use

opioids

RISEOK

Opioid-Related Disorders

2019-nCOV

PMID (1):

33037590

MeSH

opioid-related disorders

Prejudice

An argument for not firing patients for opioid misuse. James W. Mold, MD, MPH

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Physicians have a legal and ethical duty to protect their patients and support them during times of clinical need; the decision to end a doctor-patient relationship should not be made lightly. However, in a recent survey of 794 primary care practices, 90% reported discharging patients in the previous two years, often for opioid-related issues.1 Disruptive or inappropriate behavior was the most common reason for discharge (81%), but 78% reported dismissing patients for violations of a chronic pain or controlled substance agreement. We find this practice worrisome, particularly since many controlled substance agreements use coercive and stigmatizing language that patients may reluctantly sign or have trouble understanding.2 Although violent, threatening, or disruptive behavior may be a valid reason to discharge patients in certain circumstances, opioid misuse should rarely rise to this threshold

Author/s:

Tobin, Daniel G., Holt, Stephen R., Doolittle, Benjamin R.

Association of Current Opioid Use With Serious Adverse Events Among Older Adult Survivors of Breast Cancer

Devin Evans — Wed, 03 Mar 2021 06:00:00 +0000

Date Added:

March 3, 2021

Journal/Publication:

Journal of the American Medical Association Network Open

Publication Date:

September 1, 2020

Issue:

Volume:

URL:

Association of Current Opioid Use With Serious Adverse Events Among Older Adult Survivors of Breast Cancer

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2020.16858

Keywords

RISEOK

aged

elderly

Opioid-Related Disorders

opioids

pain management

PMID (1):

32930779

MeSH

opioid-related disorders

drug overdose

This study documented a wide range of serious adverse events in older breast cancer patients prescribed opioids after surgery. James W. Mold, MD, MPH

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Importance: National efforts to improve safe opioid prescribing focus on preventing misuse, overdose, and opioid use disorder. This approach overlooks opportunities to better prevent other serious opioid-related harms in complex populations, such as older adult survivors of cancer. Little is known about the rates and risk factors for comprehensive opioid-related harms in this population.

Objective: To determine rates of multiple opioid-related adverse drug events among older adults who survived breast cancer and estimate the risk of these events associated with opioid use in the year after completing cancer treatment.

Design, setting, and participants: This retrospective cohort study used 2007 to 2016 Surveillance, Epidemiology and End Results-Medicare data from fee-for-service Medicare beneficiaries with first cancer diagnosis of stage 0 to III breast cancer at age 66 to 90 years from January 1, 2008, through December 31, 2015, who completed active breast cancer treatment. Data were analyzed from October 31, 2019, to June 10, 2020.

Exposures: Repeated daily measure indicating possession of any prescription opioid supply in Medicare Part D prescription claims.

Main outcomes and measures: Adjusted risk ratios (aRRs), estimated using modified Poisson generalized estimating equation models, for adverse drug events related to substance misuse (ie, diagnosed opioid abuse, dependence, or poisoning), other adverse drug events associated with opioid use (ie, gastrointestinal events, infections, falls and fractures, or cardiovascular events), and all-cause hospitalization associated with opioid supply the prior day, controlling for patient characteristics.

Conclusions and relevance: These findings suggest that among older adults who survived breast cancer, continued prescription opioid use in the year after completing active cancer treatment was associated with an immediate increased risk of a broad range of serious adverse drug events related to substance misuse and other adverse drug events associated with opioid use. Clinicians should consider the comprehensive risks of managing cancer pain with long-term opioid therapy.

Author/s:

Winn, Aaron N., Check, Devon K., Farkas, Amy, Fergestrom, Nicole M., Neuner, Joan M., Roberts, Andrew W.

Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations

Carly Hughes — Tue, 06 Oct 2020 13:44:48 +0000

Date Added:

October 6, 2020

Journal/Publication:

Mayo Clinic Proceedings

Publisher:

Mayo Clinic

Publication Date:

October 2, 2020

Issue:

Volume:

Pages:

2155-2171

URL:

Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2020.04.025

Keywords

opioids

Opioid-Related Disorders

MeSH

opioid-related disorders

A 16-page comprehensive guide to evaluating and tapering opioids developed by a panel pain management clinicians with patient input. James W. Mold, MD, MPH

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Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with long-term use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing. Although opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. Thus, health care professionals who reduce or discontinue long-term opioid therapy require a clear understanding of the associated benefits and risks as well as guidance on the best practices for safe and effective opioid reduction. An interdisciplinary panel of pain clinicians and one patient advocate formulated recommendations on tapering methods and ongoing pain management in primary care with emphasis on patient-centered, integrated, comprehensive treatment models employing a biopsychosocial perspective.

Author/s:

Covington, Edward C, Argoff, Charles E, Ballantyne, Jane C, Cowan, Penney, Gazelka, Halena M, Kertesz, Stefan G, Manhapra, Ajay, Murphy, Jennifer L, Stanos, Steven P Jr., Sullivan, Mark D

Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings

Brian Desmarais — Tue, 01 Sep 2020 13:25:16 +0000

Date Added:

September 1, 2020

Journal/Publication:

NAM Perspectives

Publisher:

National Academy of Medicine

Publication Date:

August 10, 2020

URL:

Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.31478/202008c

Keywords

Opioid-Related Disorders

MeSH

A fairly long summary of the evidence and some reasonable guidance from the National Academy of Medicine about how to think about opioid tapering in patients with non-cancer pain. James W. Mold, MD, MPH

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Not available.

Author/s:

Rich, Robert, Mariano, Edward R., Dopp, Anna Legreid, Sullenger, Rebecca, Burstin, Helen