Opioid Use

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

Trajectories of Opioid Use Following First Opioid Prescription in Opioid-Naive Youths and Young Adults

Devin Evans — Thu, 29 Apr 2021 05:00:00 +0000

Date Added:

May 19, 2021

Journal/Publication:

Journal of the American Medical Association Network Open

Publication Date:

April 1, 2021

Issue:

Volume:

URL:

Trajectories of Opioid Use Following First Opioid Prescription in Opioid-Naive Youths and Young Adults

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2021.4552

Keywords

PMID (1):

33885777

MeSH

opioid-related disorders

prescriptions

Very interesting study showing two distinct patterns of opioid use behaviors among adolescents after being given a first opioid prescription for pain. Predictors of subsequent misuse were identified. James W. Mold, MD, MPH

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Importance: Although prescription opioids are the most common way adolescents and young adults initiate opioid use, many studies examine population-level risks following the first opioid prescription. There is currently a lack of understanding regarding how patterns of opioid prescribing following the first opioid exposure may be associated with long-term risks.

Objective: To identify distinct patterns of opioid prescribing following the first prescription using group-based trajectory modeling and examine the patient-, clinician-, and prescription-level factors that may be associated with trajectory membership during the first year.

Design, setting, and participants: This cohort study examined Pennsylvania Medicaid enrollees' claims data from 2010 through 2016. Participants were aged 10 to 21 years at time of first opioid prescription. Data analysis was performed in March 2020.

Main outcomes and measures: This study used group-based trajectory modeling and defined trajectory status by opioid fill.

Results: Among the 189 477 youths who received an initial opioid prescription, 107 562 were female (56.8%), 81 915 were non-Latinx White (59.6%), and the median age was 16.9 (interquartile range [IQR], 14.6-18.8) years. During the subsequent year, 47 477 (25.1%) received at least one additional prescription. Among the models considered, the 2-group trajectory model had the best fit. Of those in the high-risk trajectory, 65.3% (n = 901) filled opioid prescriptions at month 12, in contrast to 13.1% (n = 6031) in the low-risk trajectory. Median age among the high-risk trajectory was 19.0 years (IQR, 17.1-20.0 years) compared with the low-risk trajectory (17.8 years [IQR, 15.8-19.4 years]). The high-risk trajectory received more potent prescriptions compared with the low-risk trajectory (median dosage of the index month for high-risk trajectory group: 10.0 MME/d [IQR, 5.0-21.2 MME/d] vs the low-risk trajectory group: 4.7 MME/d [IQR, 2.5-7.8 MME/d]; P < .001). The trajectories showed persistent differences with more youths in the high-risk trajectory going on to receive a diagnosis of opioid use disorder (30.0%; n = 412) compared with the low-risk group (10.1%; n = 4638) (P < .001).

Conclusions and relevance: This study's results identified 2 trajectories associated with elevated risk for persistent opioid receipt within 12 months following first opioid prescription. The high-risk trajectory was characterized by older age at time of first prescription, and longer and more potent first prescriptions. These findings suggest even short and low-dose opioid prescriptions can be associated with risks of persistent use for youths.

Author/s:

Wilson, J.D., Zbebe, K.Z., Kraemer, K., Liebschutz, J., Merlin, J., Miller, E., D., Donohue, J.

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.