July 24, 2017

Opioid prescribing in the United States quadrupled between 1999 and 2015, the Centers for Disease Control and Prevention (CDC) reports. In that time, more than 183,000 people died from overdoses related to prescription opioids.  These numbers alone point to the need for pain specialists, anesthesiologists and nurse anesthetists to stay abreast of news and research about opioids that can be used to inform and improve their practices.  The eclectic array of items presented here provides a minute sampling of the current information.  Hopefully, it will be useful and spark further thinking and discussion.

Anxiety, Depression, Opioids

A study directed primarily to family medicine physicians, who write the largest number of opioid prescriptions, offers food for thought for pain specialists and anesthesia providers as well.  An analysis of data from 2011 and 2013, published online July 5 in the Journal of the American Board of Family Medicine, found that approximately 19 percent of the estimated 38.6 million people with the two most common mental health disorders—anxiety and depression—received at least two prescriptions for opioids in a year.  Fifty-one percent of all opioid prescriptions went to patients in this group.

These patients may have some form of physical pain, but a pain level others might report as a 2, a person with depression or anxiety might report as a 10, according to Brian Sites, MD, the anesthesiologist at Dartmouth-Hitchcock Medical Center who led the study.  “Their mental condition may cause them to feel that pain more acutely or be less able to cope with it, leading to increased requests for something to dull it,” Dr. Sites said in a Washington Post article.

Source:  Journal of the American Board of Family Medicine, Prescription Opioid Use Among Adults with Mental Health Disorders in the United States, July 5, 2017.

Five-Question COMM Saves Time

Researchers have pared down an effective screening tool into five questions that would allow physicians to more quickly and efficiently identify opioid-related aberrant behavior that could signify abuse or addiction.  The 17-question Current Opioid Misuse Measure (COMM) can take about 10 minutes to complete, and that’s too long for a typical 15-minute visit.

The shortened form is as effective as the original, according to researchers at Memorial Sloan Kettering Cancer Center in New York City, who presented their work at ANESTHESIOLOGY^® 2016 (abstract 1051).  Specialists in pain medicine, palliative care, psychology, neurology and other fields at the hospital’s multimodal pain clinic helped shape the shorter instrument.

The questions ask about activities and behaviors during the past 30 days:

• How often have you had to go to someone other than your prescribing physician to get sufficient pain relief from medications (e.g., another doctor, the emergency room, friends, street sources)?
• How often have you taken your medications differently from how they are prescribed?
• How much of your time was spent thinking about opioid medications (having enough, taking them, dosing schedule, etc.)?
• How often have others been worried about how you’re handling medications?
• How often have you used your pain medicine for symptoms other than for pain (e.g., to help you sleep, improve your mood or relieve stress)?

Statistical analysis revealed good specificity and sensitivity between the short and long versions of the COMM.

Source:  Anesthesiology News, March 1, 2017

Think Waste Management in Drug Diversion Prevention

When it comes to preventing controlled substance diversion at your hospital, don’t forget the waste stream.  Sharps bins and waste containers are often overlooked in protocols as potential sources of controlled drugs for a drug-seeking staff member, visitor or patient.

A patient care aide at one institution found a reliable source of opioids in the hospital’s trash—a place her facility hadn’t included in its diversion prevention protocol.  The aide, who eventually died of an overdose of rocuronium, had been collecting discarded vials and syringes containing tiny unused amounts of fentanyl and morphine and sneaking them out of the hospital in her backpack. 

In a similar vein, hasty drug-wasting practices also can lead to diversion.  Healthcare professionals trust the people they’re working with, so they might not watch them waste the drug, thereby giving a staff member the chance to pocket the drug or shoot it into a vial.

The American Society of Health System Pharmacists and the Institute for Safe Medicine Practices have issued updated recommendations for drug diversion prevention that incorporate waste management issues, including:

• Use sharps/pharmaceutical waste containers, ideally ones that render waste unrecoverable and unusable, or ones with small openings that make it hard to shake out waste and devices.
• Never discard waste medications in vials or prefilled syringes directly into sharps containers.  Have an independent witness verify the volume and dose and watch while the drug is squirted into a waste box.
• Consider including other high-alert medications in controlled substance disposal policies, including neuromuscular blocking agents (e.g., rocuronium), concentrated electrolytes and propofol.  These are desirable for diversion but not included on lists of controlled substances in many states.
• Educate all staff who come into contact with controlled substance waste about proper handling and disposal.  People who are not involved in the use and handling of controlled drugs often have no idea about the diversion potential of medical waste.  

Source:  Anesthesiology News, June 22, 2017. Also see our eAlert on the need for anesthesia providers to be involved in developing effective drug diversion prevention policies, procedures and programs at their facilities, especially in light of the Drug Enforcement Administration’s heightened scrutiny of healthcare organizations.

Funds to Fight Overdoses and Deaths

The CDC has given $12 million in expanded federal funds to 23 states and the District of Columbia to support efforts to reduce opioid overdoses through prevention and monitoring.  The funds are being awarded through the Enhanced State Surveillance of Opioid-Involved Morbidity and Mortality (ESOOS) program and the Prescription Drug Overdose: Prevention for States (PfS) program.

States can use the ESOOS funds to:

• More quickly report nonfatal and fatal opioid overdoses and risk factors related to fatal overdoses.
• Share data with stakeholders working to prevent opioid overdoses.
• Share data with CDC to improve surveillance and response to opioid overdoses.

The PfS funding will allow states to enhance prescription drug monitoring programs (PDMPs) and implement and evaluate strategies to improve opioid prescribing practices.

The expanded funding supports the Department of Health and Human Services’ five-point strategy to combat the opioid addiction and misuse epidemic, which seeks to:

• Improve access to prevention, treatment and recovery services;
• Target availability and distribution of overdose-reversing drugs;
• Strengthen timely public health data and reporting;
• Support research on pain and addiction; and
• Promote better pain management practices. 

Source: Centers for Disease Control and Prevention, July 17, 2017

Prescriptions Down, But Vary Widely

The amount of opioids prescribed in the U.S. has dropped each year for the past six years from a peak per capita of 782 morphine milligram equivalents (MME) in 2010 to 640 in 2015.  Still, the most recent number is three times higher than in 1999 and varies widely by county, with physicians in some counties prescribing as much as six times more opioids than others.  This variation highlights the need for clinicians to use evidence-based guidance when prescribing opioids, according to Deborah Dowell, MD, of the CDC.  MME per capita decreased in half of U.S. counties and increased in 23 percent of counties.

Source: Vital Signs, Opioid Prescribing:  Where You Live Matters, Centers for Disease Control and Prevention, July 6, 2017.

Gender, Age, Inpatient Stays and Emergency Department Visits

Opioid-related hospital stays rose dramatically for both men and women between 2005 and 2014, but the rate of increase in hospitalizations for women outpaced that of men during this time, according to a report from the Agency for Healthcare Research and Quality. 

Opioid-related hospital stays increased 55 percent for men but 75 percent for women.  In 2005, the rate of opioid-related inpatient stays was higher for males, but by 2014, the rate was the same for both sexes.

Other key findings of the study:

• The increase in the rate of opioid-related emergency department visits during this period was similar for males and females, but males had persistently higher rates.
• Inpatient stays in most states were higher among females in 2014; however, males had a higher rate of emergency department (ED) visits.
• Patients in the 25-44 and 45-64 age groups had the highest rates of inpatient stays nationally.
• Patients aged 25-44 years had the highest rate of ED visits in all states.
• Across all groups in 2014, Iowa, Nebraska, Texas and Wyoming had the lowest rates of inpatient stays and Massachusetts had the highest. Arkansas and Iowa had the lowest rates of ED visits and Maryland the highest.  

Source: Agency for Healthcare Research and Quality, Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009-2014.

Best Practices for PDMPs

Though many physicians have resisted requirements to use state prescription drug monitoring programs (PDMPs), a 2016 study published in Health Affairs found that prescriptions of Schedule II opioids decreased by 30 percent among 24 states from 2000 to 2010 after they started operating PDMPs.

A report published in December 2016 by Brandeis University outlines best practices for PDMPs that could help overcome some of the obstacles to successful implementation as well as resistance from some clinicians.  The best practices are:

• Adopt a uniform and latest reporting standard of the American Society for Automation in Pharmacy (ASAP).  Uniform data collection standards improve data quality, analysis and sharing.
• Collect positive identification for the person picking up prescriptions to lessen the risk of fraud, abuse and diversion.
• Reduce the data collection interval and move toward real-time data collection.  The most up-to-date prescription history increases PDMP data utility for clinical practice and drug diversion investigations.
• Collect data on method of payment, including cash transactions.  Cash payment can point to questionable activity.  Doctor shoppers and pill mill operators often pay in cash.
• Integrate PDMP data with health information exchanges.  Simplifying access to the PDMP increases the likelihood that prescribers and dispensers will use prescription history information in clinical decision-making.
• Send unsolicited reports and alerts to appropriate users.  Many PDMPs employ these methods to alert prescribers that a patient might be engaged in questionable activity, such as doctor shopping, or is at risk of overdose.
• Mandate PDMP enrollment.  To remedy under-utilization, many states have mandated that prescribers and dispensers enroll in the PDMP to encourage physicians to use the PDMP in clinical care.
• Mandate utilization to increase the number of practitioners who use the PDMP.  Unlike enrollment, utilization is typically mandated under certain circumstances, such as before prescribing a controlled substance to a new patient.
• Delegate access.  Allowing office staff to access the PDMP on the practitioner’s behalf can encourage utilization.
• Enact and implement interstate data-sharing among PDMPs.  Interstate sharing of data is now a top priority for PDMPs to ensure that clinicians have a complete picture of their patients’ prescription history.
• Obtain secure funding.  Secure funding is defined as that coming from state revenue sources or non-grant sources.

Source:  Enhancing PDMPs: A Comparison of Changes 2010 to 2016, The Heller School for Social Policy and Management, Brandeis University, December 2016.

Beta Blockers as an Opioid-Sparing Technique

Replacing fentanyl with esmolol in the perioperative period yielded short- and long-term benefits in a study of patients undergoing arthroscopic shoulder surgery with continuous brachial plexus blockade.

The opioid-sparing technique was associated with a decrease in unanticipated hospitalizations from 11.4 to 2.3 percent and a drop in 30-day emergency department visits from 12.5 to 3.4 percent, reported Emily Buckley, CRNA, of Phelps County Regional Medical Center in Rolla, MO, at the 2017 meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 3775).  Esmolol was part of multimodal pain management that included ketorolac, dexamethasone and ondansetron.

“Many of our patients were leaving the medical center and quickly re-entering the health care system,” said co-author Michael Burns, CRNA.  “With the initiation of this protocol, however, we had a risk change from one out of four patients being readmitted within 30 days or unanticipated admission the day of surgery to one out of 16.”

Source:  Anesthesiology News, June 8, 2017.

The fact that 91 people died each day in 2015 in the U.S. of overdoses of prescription painkillers, heroin, fentanyl and other opioids offers a sobering reminder that opioids can wreak havoc.  Yet, as anesthesia providers, you know that opioids have value when used judiciously and carefully.  And so, the intricate balancing act and weighing of the pros and cons continues.  We’ve barely scratched the surface of the available research and information, but we hope these items contribute in some small way to helping you sift through the nuances of a complex issue.

With best wishes,

Tony Mira
President and CEO