Drug overdose is now the leading
cause of injury-related death, surpassing both motor vehicle accidents and gun homicides/suicides.
As many as 1 in 10 patients prescribed an opioid will struggle with
dependence/addiction, and 1 in 550 will die from an opioid overdose at a median
of 2.6 years. Furthermore, up to 1 in 4 patients does not use their entire
opioid prescription, and the majority of patients leave excess medications in
their home; this increases the risk of other individuals in the home (e.g.,
young children) finding the drug and accidentally overdosing.
In 2016, the CDC put forth
guidelines1 for best practices regarding opioid prescribing for
chronic pain. Among these were a number of recommendations regarding short-term
opioid use, such as:
·
Minimize opioid use by maximizing use of
nonpharmacologic and nonopioid pharmacologic pain treatments.
·
Establish goals for analgesia and discuss risks
and realistic benefits of opioids before
starting opioid therapy.
·
Avoid extended release or long acting opioids.
·
Prescribe the lowest effective dosage,
preferably less than 50 morphine milligram equivalents (MME) per day; doses
over 90 MME per day should be fully justified.
·
Prescribe no greater quantity than needed for
the expected duration of pain severe enough to require opioids (CDC recommends
3-7 days, but other organizations suggest a 14-day maximum from acute
injury/surgery2).
·
Review the patient’s PDMP (i.e., KASPER) data
before prescribing.
·
Utilize urine drug screening before prescribing
opioids.
·
Avoid concomitant opioids and benzodiazepines.
·
Offer or arrange evidence-based treatment
(usually medication-assisted treatment) for patients with opioid use disorders.
·
Mitigate risk of harm when opioids are
prescribed, specifically by offering naloxone when factors that increase risk
of overdose are present.
Specific risk factors for overdose include:
Patients who meet criteria should
be prescribed naloxone on discharge. The branded intranasal naloxone product
(Narcan®) is covered by most insurance and readily available at most
pharmacies, including all University of Kentucky retail pharmacies. The
following link is to a searchable database providing information on any
pharmacy in Kentucky that dispenses naloxone: http://odcp.ky.gov/Stop-Overdoses/Pages/Locations.aspx. This information is also available
on the Narcan® website, www.narcan.com.
The prescription should contain the following:
Drug – Naloxone (or Narcan) 4mg/0.1mL nasal spray
Drug – Naloxone (or Narcan) 4mg/0.1mL nasal spray
Dosage – 4mg intranasal once, can repeat in 2-3 minutes if
needed
Quantity – 2
The patient should be given discharge instructions regarding
intranasal naloxone use, available on KRAMES, which will be given again at
discharge.
References:
1.
Dowell D, Haegerich TM, Chou R. CDC guideline
for prescribing opioids for chronic pain—United States, 2016. JAMA 2016; 315:
1624-45.
Patient/Family Education Material (available on Krames and from PharmD)
