Navigating the Landscape in Opioid Prescribing

Author: Jeffrey Fudin

Patient screening and risk management in opioid therapy is really quite a challenge and requires significant knowledge of the medications particularly with high-dose opioids.  First of all, you have to make a decision of whether or not, as the dose escalates, the patient should even be on opioids because if they have to keep going up over a short period of time, maybe it’s not an appropriate drug. On the other hand, there could be justification of why a patient may need a high-dose opioid and another patient may need another opiate, or the same patient may require a high-dose opioid of one morphine equivalent and a lower dose of another drug. It’s really very complicated.  You need to know the pharmacology and the pharmacokinetics of the drugs.

It’s very important for practitioners to understand all at least all the standard tests that are available. There are hair follicle tests.  There are saliva tests.  But the standard of care really is urine testing. Doctors, nurse practitioners, PAs, PharmDs have to understand if you’re doing a urine test, you need to know the difference between an immunoassay test and a quantitative confirmation or a confirmation by chromatography. There are flaws in the immunoassay test.  It’s a good test for point of care because it helps you determine whether the patient is taking the drugs.  If everything was equal, if all doctors had chromatography testing in their office and the costs were equal, there should be no immunoassay test.  But that’s not where we live. So we need to justify in the chart why we’re sending the tests out for quantitative confirmation, why we’re incurring that cost, and then when those results come back, we need to document that very well.

Opioid-induced constipation can be quite a problem for a lot of patients.  This is an area where all healthcare providers really need to be familiar with the kinds of drugs that are available.

Patients sometimes do not feel comfortable discussing constipation with their care provider, or they are afraid that they’re going to lower their opioid dose or change it to another drug.  Their care provider has other things to ask the patient, so if the patient doesn’t complain about opioid-induced constipation, it isn’t brought up. Patients will then try to treat the constipation themselves, with senna, docusate, other over the counter medications, that are expensive and oftentimes don’t work.  Sometimes they do work, but they can cause cramping, diarrhea.  They can cause depletion of certain electrolytes.  So they’re not without issues. We have a new group of drugs called PAMORAs, which is an acronym that stands for peripherally-acting mu-opioid receptor antagonist, and is basically a direct antidote for how the opioids cause constipation in the gut. Not everybody needs to be on a PAMORA because some patients do just fine on standard therapy for constipation.  But I think that it’s important that healthcare providers have an understanding of the drugs that are available to treat opioid-induced constipation and keep this in mind as an alternative.

When thinking about abuse-deterrent formulations and opioid risk, there are pros and cons. From a public health standpoint, it’s probably a good thing to have drugs that are presumably safer, and there are a number of different abuse-deterrent technologies available. But they are expensive, and patients without good insurance—who may be at the highest risk—may not be covered. The other thing is that abuse-deterrent formulations are just that – they are deterrent.  So they may slow down the ability of a person to abuse these drugs, but it doesn’t mean that it goes away.  So there are a lot of issues.  I don’t think that they’re the be all and end all to opioid therapy, but I do think it’s a step in the right direction. In dealing with overdose response, the AMA and other organizations have advocated for dual prescribing of in-home naloxone for patients at risk who are put on opioid therapy.  It’s been argued that if they’re a high risk, shouldn’t we just not give the opioid and forget about the naloxone. But that’s not really acceptable because there are a lot of patients who need opioids.  Other drugs either don’t work, they’re not indicated, or they’re contraindicated for the type of pain that the patient has. There are a lot of risks in patients that are on legitimate combinations of medications that are totally unpredictable. And so, I think patients should be prescribed dual therapy. There should be an escape plan, and the naloxone in the house should be accessible to everyone.

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