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  • Prescribing Opioids: Guidelines for Safer Use

    A recent push for judicious opioid prescribing and more appropriate stewardship of their use has been called for by the CDC. Fueled by increasingly concerning statistics, as well as a general increase in the use of opioids for the management of chronic pain, clinicians should always use great caution when initiating and managing opioid medications.

    The greatest concern with opioid use, which is its overdose and addiction liability, is becoming profoundly more apparent. There were over 33,000 opioid-related deaths reported in 2015 alone, and since 2000, the rate of drug overdose deaths has increased by 137% with opioid-related deaths up by 200%.1,2 Due to the consequences of abuse, the FDA has for the first time taken steps to remove a currently marketed opioid pain medicine, Opana ER (oxymorphone hydrochloride), from sale.3

    In their most recent publication regarding opioid use, the CDC provides multiple recommendations with respect to the initiation, selection, and monitoring of opioid use for chronic pain in patients. Listed are several key points:

    • Nonpharmacologic and nonopioid pharmacologic therapies are preferred for chronic pain; clinicians should utilize opioids only if the benefits are expected to outweigh the risks
      • There is no evidence to support a long-term benefit in opioid use compared to non-opioid use for chronic pain in patients whose long-term outcomes were examined
    • Establish treatment goals and discuss known risks and realistic benefits with all patients
    • Prescribe immediate-release opioids instead of extended-release formulations when initiating opioids, and prescribe no greater quantity than needed for the expected duration of pain
    • Utilize prescription drug monitoring programs (PDMPs) and review patient’s history and risk factors for opioid-related harms (history of overdose, history of substance use, concomitant benzodiazepine use)

    To combat the opioid overdose epidemic, the FDA is also encouraging the development of opioids with abuse-deterrent properties. Several extended-release/long-acting opioids have been approved by the FDA with abuse-deterrent properties labeling. These opioid formulations deter improper use via nasal inhalation, crushing or IV use.4 While abuse-deterrent opioids may help combat misuse and abuse, it is important to note that these are not abuse-proof. For example, although Opana ER was specifically formulated to help prevent crushing and snorting of the medication, a review of postmarketing data showed a significant shift in the route of abuse of the product from nasal to injection after its reformulation.

    Ultimately, practitioners must use proper judgment in the use of opioids for the management of pain. The utilization of non-opioids, nonpharmacologic therapy, patient history review and PDMPs, and good clinical practice can often significantly improve patient outcomes and experiences. Policies and positions on long-term opioid prescribing must also address the needs of patients with chronic pain who do benefit from the treatment and do not misuse the drugs. Further recommendations and clinical guidelines from the CDC are available.

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    References: 1) Drug Overdose Death Data. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugoverdose/data/statedeaths.html. Updated December 16, 2016. Accessed July 14, 2017. 2) Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014. Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention website. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm. Updated January 1, 2016. Accessed July 14, 2017. 3) FDA requests removal of Opana ER for risks related to abuse. U.S. Food and Drug Administration website. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm562401.htm. Updated June 6, 2017. Accessed July 14, 2017. 4) FDA Facts: Abuse-Deterrent Opioid Medications. U.S. Food and Drug Administration website. https://www.fda.gov/NewsEvents/Newsroom/FactSheets/ucm514939.htm. Updated April 21, 2017. Accessed July 14, 2017.