January 18, 2018
Opioids are unique medications. Their original commercial formulations, including heroin prior to its 1924 federal prohibition, were marketed as "wonder drugs" capable of relieving immense pain while simultaneously inducing euphoria. Despite the clear analgesic benefits, the accompanying risk of addiction made many physicians reluctant to prescribe medicines in this class until the 1990s.
Since then, there has been a surge in prescribed opioids, along with a similarly sharp rise in deaths from overdosing on natural, synthetic and semi-synthetic opioids. According to the Centers for Disease Control and Prevention (CDC), the increase in prescriptions from 1999 to 2014 did not correspond to any uptick in reported pain. That disconnect suggests inconsistent prescribing practices, as well as several common dispensation errors recognized by the CDC, including:
The culture of prescription drugs is slowly evolving so that opioids are used in quantities and therapies reflecting their safety profiles. In practice, this means seeking alternatives when feasible and, if prescribing opioids, devising a well-defined treatment duration and (if needed) tapering schedule. One resource for ensuring a system of accountability around responsibly prescribing opioids is an independent review organization (IRO).
At Advanced Medical Reviews (AMR), a Los Angeles-based IRO, drug utilization reviews, whether prospective, concurrent, or retrospective, are a valuable resource for payers and providers alike when navigating the complexities of evidence-based guidelines, weaning and tapering schedules, and alternative analgesics. As Jeff Schulze, VP of Enterprise Accounts explains, "One of AMR's strongest assets is our diverse, nationwide network of physician reviewers. Opioids are prescribed for pain management by physicians of all specialties, and being able to match physicians for peer-to-peer reviews according to specialty and state guidelines significantly strengthens the quality and accuracy of the review."
Tapering is central to effective and safe opioid consumption for many patients. It is the ideal "exit strategy" to minimize risk.
Importantly, rapid discontinuation can trigger withdrawal symptoms, including anxiety, cramping and nausea. Recently detoxified patients account for the bulk of opioid-related deaths, since they quickly lose tolerance for the medications and can overdose on doses lower than those they previously took, according to MedlinePlus.
Accordingly, taper schedules need to be precisely planned and customized for each patient through consultation with specialists and treatment experts, as needed. The broad spectrum of patients taking opioids - for conditions as varied as cancer and lower back pain – makes generalized tapering approaches difficult to reach consensus, but the CDC has helpfully made some recommendations here, such as:
1. Initiating the Taper in Response to Specific Signs
Sometimes a patient requests a taper. In other instances, the physician should take the initiative by looking for:
2. Going Slowly
Lowering the original dose by 10 percent per week is appropriate for most patients. For chronic opioid users, the taper should be slower.
3. Offering Support Along the Way
Coordinating with mental health providers is often an important component of opioid tapers. Naloxone (Narcan®) is used to reverse overdoses and should be widely available. Comprehensive opioid-substitution therapy includes buprenorphine (Buprenex®) and buprenorphine/naloxone (Suboxone®).
4. Monitoring the Patient's Response
How a patient responds to the taper will determine the strategy's progression. Rate and duration may be modified, but the taper itself should not be reversed. Once opioids are taken less than once daily, they can usually be discontinued.
Opioid addiction is a problem capable of affecting many patients suffering from a pain ailment. Physicians make a major difference in whether patients use opioids and, if so, how they take and ultimately discontinue them. Custom tapers based on careful evidentiary observations, realistic expectations and encouragement of patients (many of whom will achieve better quality of life on fewer or no opioids) can improve public health by reducing risk of death.
Success requires awareness of available complementary and alternative treatments, from non-opioids to behavioral health support. Working with IROs is a key partnership for payers and providers evaluating options and arriving at the most beneficial treatments for their patients.
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