Opioid Safety Prescribing Guidelines, Quality Measures, and Care Coordination.
Learning Objectives
- Describe the current climate of opioid use,
misuse, and social impact. - Summarize the recommendations of the CDC
Guideline for Prescribing Opioids for Chronic Pain; - Recognize factors that increase the risk for opioid
harm and care coordination practices to improve
the safe use of opioids; - Identify emerging quality measures related to
opioid prescribing
CDC Opioid Training for Nurses
CDC released a new module, A Nurse's Call to Action for Safer Opioid Prescribing Practices, in the interactive online training series Applying CDC’s Guideline for Prescribing Opioids. This module helps nurses learn how they can support the implementation of the CDC Guideline to address the opioid overdose epidemic. From a nursing perspective, participants will learn risk mitigation strategies, quality improvement practices, patient communication techniques, and care coordination approaches that support safer opioid prescribing. Clinical scenarios, knowledge feedback prompts, and a resource library are used to enhance learning. All trainings in the series feature recommendations from CDC’s Guideline for Prescribing Opioids for Chronic Pain, offer free continuing education, and are available on our Training for Providers webpage.
Harvard Course: The Opioid Crisis in America
Learn about the opioid epidemic in the United States, including information about treatment and recovery from opioid addiction.
About this course
Length:
Effort:
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7 weeks
1-2 hours per week
Free - Add a Verified Certificate for $99.00
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Video Transcripts:
HarvardX
Medicine
Introductory
English
English
This course is available for Continuing Education credit. Enroll in the course to learn more about options for earning credit. Currently credits are available for:
Opioids are part of a drug class that includes the illegal drug heroin as well as powerful pain relievers, such as oxycodone, hydrocodone, codeine, morphine, fentanyl, and many others.
In 2015 more than 33,000 people died from overdoses involving opioids. Every day in the United States more than 1,000 people are treated in emergency departments for not using prescription opioids as directed. Drug overdose is now the leading cause of accidental death in the U.S., and opioid addiction is driving this epidemic.
This course challenges preconceptions about addiction and about who can become addicted to opioids. Our main goals are to reduce the stigma that exists around addiction, help prevent overdose deaths and encourage people to learn about the multiple pathways to treatment. You will learn about these topics from a variety of medical experts and hear from people who have experienced addiction themselves, or who have lost a family member to an overdose.
What you'll learn
In this course, you will learn about opioid use and addiction and how it has evolved over time, leading to the current public health crisis in the United States. We will cover all of the following points:
- Medical and non-medical use of opioids, including heroin and fentanyl
- How to manage pain with and without opioids
- The risks and neurological pathways to opioid addiction
- That addiction is a disease of the brain, not a lack of will, and there are multiple ways people can become addicted to opioids
- How men and women experience opioid addiction and treatment differently
- How opioid addiction impacts adolescents and young people
- The individual and social impacts of opioid addiction
- The latest harm reduction approaches that law enforcement and public health officials are using to reduce opioid overdose deaths
- Empathic evidence-based behavioral approaches and effective medications that health care professionals can offer people who have an addiction to opioids
- How the path to recovery is not always straightforward, but there is life after addiction
Across seven lessons, you will learn about the origins and spread of opioid use, misuse, and addiction. Our experts also cover the appropriate ways in which this class of drugs can be used to treat specific pain conditions. We also explore deeply the impact of opioid misuse on the individual, family, and community. The course includes information about the differences between men and women when it comes to addiction and treatment, as well as the particular risks of opioid addiction in young people. And throughout the course, you will see and hear stories from people who are in recovery and those who have lost family members to overdose. While our course is not intended to serve as medical advice, you will learn about a wide variety of treatment options available to people with addiction.
Course Syllabus
Lesson 1: How has opioid misuse evolved and spread? Why is this a public health crisis in America?
Lesson 2: Are opioids "bad" drugs, or are there appropriate ways to use them?
Lesson 3: What counts as misuse and what can happen when you misuse opioids?
Lesson 4: How does opioid addiction affect an individual, their family, and the community?
Lesson 5: How can opioid overdose be treated and prevented?
Lesson 6: How can opioid misuse and addiction be treated?
Lesson 7: What does the process of long-term recovery from opioid addiction look like?
U.S. Surgeon General’s “TurnTheTideRx.org”
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As part of U.S. Surgeon General Vivek Murthy’s national campaign on the prescription opioid epidemic, he has launched a website called TurnTheTideRx.org, which "provides critical information about opioids, including risks, benefits and clear guidance on how best to prescribe these medications. There are also tools for treatment and in-the-trenches stories from colleagues who are on the front lines of fighting this epidemic."
For more information and to visit the website please Click Here.
Pain Expert: 'I Haven't Prescribed an Opioid in a Decade'
F. Perry Wilson, MD, MSCE; and Daniel Clauw, MD
Daniel Clauw, MD, states the case for avoiding opioids in chronic pain
Daniel Clauw, MD, is professor of medicine, anesthesia, and psychiatry at the University of Michigan and director of the Chronic Pain and Fatigue Research Center. In this era of increasing opioid abuse and overdoses, and harsh criticism for physicians' use of opioids in the setting of chronic pain, he shared his (not at all subtle) opinion in a "Doc to Doc" conversation with me.
Despite treating patients with a range of chronic pain issues, from fibromyalgia to interstitial cystitis to low back pain, Clauw says, "I haven't prescribed an opioid for chronic pain in at least a decade."
Reducing the Risks of Relief — The CDC Opioid-Prescribing Guideline
Deaths from prescription-opioid overdose have increased dramatically in the United States, quadrupling in the past 15 years. Efforts to improve pain management resulted in quadrupled rates of opioid prescribing, which propelled a tightly correlated epidemic of addiction, overdose, and death from prescription opioids that is now further evolving to include increasing use and overdoses of heroin and illicitly produced fentanyl.
The pendulum of opioid use in pain management has swung back and forth several times over the past 100 years. Beginning in the 1990s, efforts to improve treatment of pain failed to adequately take into account opioids’ addictiveness, low therapeutic ratio, and lack of documented effectiveness in the treatment of chronic pain. Increased prescribing was also fueled by aggressive and sometimes misleading marketing of long-acting opioids to physicians.1 It has become increasingly clear that opioids carry substantial risks and uncertain benefits, especially as compared with other treatments for chronic pain.
On March 15, 2016, the Centers for Disease Control and Prevention (CDC) released a “Guideline for Prescribing Opioids for Chronic Pain” to chart a safer, more effective course.2 The guideline is designed to support clinicians caring for patients outside the context of active cancer treatment or palliative or end-of-life care. More research is needed to fill in critical evidence gaps regarding the effectiveness, safety, and economic efficiency of long-term opioid therapy. However, given what we know about the risks associated with long-term opioid therapy and the availability of effective nonpharmacologic and nonopioid pharmacologic treatment options, the guideline uses the best available scientific data to provide information and recommendations to support patients and clinicians in balancing the risks of addiction and overdose with the limited evidence of benefits of opioids for the treatment of chronic pain.
Most placebo-controlled, randomized trials of opioids have lasted 6 weeks or less, and we are aware of no study that has compared opioid therapy with other treatments in terms of long-term (more than 1 year) outcomes related to pain, function, or quality of life.2 The few randomized trials to evaluate opioid efficacy for longer than 6 weeks had consistently poor results. In fact, several studies have showed that use of opioids for chronic pain may actually worsen pain and functioning, possibly by potentiating pain perception. A 3-year prospective observational study of more than 69,000 postmenopausal women with recurrent pain conditions showed that patients who had received opioid therapy were less likely to have improvement in pain (odds ratio, 0.42; 95% confidence interval [CI], 0.36 to 0.49) and had worsened function (odds ratio, 1.25; 95% CI, 1.04 to 1.51).3 An observational case–control study of patients undergoing orthopedic surgery showed that those receiving long-term opioid therapy had significantly higher levels of preoperative hyperalgesia.4 After surgery, patients who had received long-term opioid therapy reported higher pain intensity (a rating of 7.6 vs. 5.5 out of 10) in the recovery room than patients who had not been taking opioids.
Whereas the benefits of opioids for chronic pain remain uncertain, the risks of addiction and overdose are clear. Although partial agonists such as buprenorphine may carry a lower risk of dependence, prescription opioids that are full mu-opioid–receptor agonists — nearly all the products on the market — are no less addictive than heroin. Although abuse-deterrent formulations may reduce the likelihood that patients will inject melted pills, these formulations are no less addictive and do not prevent opioid abuse or fatal overdose through oral intake.
The prevalence of opioid dependence may be as high as 26% among patients in primary care receiving opioids for chronic non–cancer-related pain.2 Risk-stratification tools do not allow clinicians to predict accurately whether a patient will become addicted to opioids, although persons with a history of mental illness or addiction are at higher risk.2 Overdose risk increases in a dose–response manner, at least doubling at 50 to 99 morphine milligram equivalents (MME) per day and increasing by a factor of up to 9 at 100 or more MME per day, as compared with doses of less than 20 MME per day.2 Overall, 1 of every 550 patients started on opioid therapy died of opioid-related causes a median of 2.6 years after the first opioid prescription; the proportion was as high as 1 in 32 among patients receiving doses of 200 MME or higher.5 We know of no other medication routinely used for a nonfatal condition that kills patients so frequently.
The new CDC guideline emphasizes both patient care and safety. We developed the guideline using a rigorous process that included a systematic review of the scientific evidence and input from hundreds of leading experts and practitioners, other federal agencies, more than 150 professional and advocacy organizations, a wide range of key patient and provider groups, a federal advisory committee, peer reviewers, and more than 4000 public comments.
Three key principles underlie the guideline’s 12 recommendations (see The CDC Opioid-Prescribing Guideline). First, nonopioid therapy is preferred for chronic pain outside the context of active cancer, palliative, or end-of-life care. Opioids should be added to other treatments for chronic pain only when their expected benefits for both pain and function are likely to outweigh the substantial risks inherent in this class of medication.
Nonpharmacologic therapies can ameliorate chronic pain while posing substantially less risk to patients. In some instances, other therapies result in better outcomes than opioids. These therapies include exercise therapy, weight loss, psychological therapies such as cognitive behavioral therapy, interventions to improve sleep, and certain procedures. The evidence review conducted in developing the guideline revealed that exercise therapy helped improve, and sustain improvements in, pain and function in patients with osteoarthritis. It did not find evidence that opioids were more effective for pain reduction than nonopioid treatments such as nonsteroidal antiinflammatory drugs for low back pain or antidepressants for neuropathic pain, but it did find that nonopioid treatments could be better tolerated and superior for improving physical function while conferring little or no risk of addiction and substantially lower risks of overdose and death.2
Second, when opioids are used, the lowest possible effective dose should be prescribed to reduce the risks of opioid use disorder and overdose. Clinicians should carefully reassess individual benefits and risks when increasing a dose to 50 MME or more per day. Doses of 90 MME or more should be avoided, or the decision to titrate above this level should be carefully considered and justified. When prescribing opioids, the rule of thumb is to “start low and go slow.”
Third, clinicians should exercise caution when prescribing opioids and should monitor all patients closely. Prescribers should mitigate risk by, for example, avoiding concurrent use of benzodiazepines if possible, reviewing data from a prescription-drug monitoring program when deciding whether to start or continue opioid therapy, offering naloxone at least to patients who are at greater risk for overdose, having a clear “off-ramp” plan to taper and discontinue therapy, reevaluating the dosage and necessity of opioid treatment regularly, and obtaining urine toxicology screening at the initiation of treatment and, for some patients, periodically thereafter. For patients who become addicted to opioids, treatment with methadone, buprenorphine, or naltrexone improves outcomes.
Initiation of treatment with opioids is a momentous decision and should be undertaken only with full understanding by both the physician and the patient of the substantial risks involved. Clinicians need to recognize the risk associated with any treatment with opioids and should prescribe only the shortest course needed. Although the guideline addresses chronic pain, many patients become addicted to opioids after being treated for acute pain. Three days of treatment or less will often be sufficient; more than 7 days will rarely be required. Some trauma and surgery may require longer courses; treatment of postsurgical pain is beyond the scope of this guideline. Furthermore, it is important to discuss storage of opioids in a secure location to prevent diversion, as well as to counsel patients regarding the overdose risk posed to household members and other persons.
Management of chronic pain is an art and a science. The science of opioids for chronic pain is clear: for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits.
The CDC Opioid-Prescribing Guidelines
1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.
4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to ≥90 MME per day or carefully justify a decision to titrate dosage to ≥90 MME per day.
6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed.
7. Clinicians should evaluate benefits and harms with patients within 1–4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use are present.
9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid-use disorder.
What opioid painkillers — which kill more Americans than heroin — do to your body and brain
Despite being legal with a doctor's prescription, opioid painkillers can come with serious health risks. The drugs belong to a larger class of drugs known as opioids, which includes legal, lab-produced drugs like oxycodone, fentanyl, and morphine as well as illegal drugs like heroin. Since they slow breathing and act on the same brain systems as heroin, opioid painkillers carry serious risks, from overdose to, in rarer cases, addiction.
We all have a series of naturally produced keys ("ligands") and keyholes ("receptors") that fit together to switch on our brain's natural reward system — it's the reason we feel good when we eat a good meal or have sex, for example.
But opioids mimic the natural keys in our brain — yes, we all have natural opioids! When they click in, we can feel an overwhelming sense of euphoria.
When prescription painkillers act on our brain's pleasure and reward centers, they can make us feel good. More importantly, though, they can work to reinforce behavior, which in some people can trigger a repeated desire to use. Read more here: http://www.businessinsider.com/mental-physical-effects-of-opioids-2016-5
Coalition to Stop Opioid Overdose Resources
Help get the word out by exploring the following promotion tools which you are free to use in your efforts:
Sample Messages:
Message #1
Opioid misuse and overdose, which are rising at unprecedented rates, are public health crises in the United States. There is an urgent need for simple and achievable prevention, treatment and recovery policies that can reduce opioid overdose. The Coalition to Stop Opioid Overdose unifies diverse groups around common policy goals and a coordinated strategy that will lead to meaningful and comprehensive opioid overdose prevention policy.
Message #2
The Coalition to Stop Opioid Overdose is an organization of state and national groups that are committed to advancing meaningful legislative and regulatory policies in response to the opioid epidemic. The Coalition’s efforts will focus around five key strategies to combat the opioid epidemic:
- Improving access to medication-assisted treatment for those with opioid addiction.
- Expanding availability of naloxone in healthcare settings and beyond.
- Enactment of the Comprehensive Addiction and Recovery Act (CARA).
- Enhancing prescription drug monitoring programs that track the dispensing and prescribing of controlled substances.
- Raising the level of opioid prescriber education.
Dr. Slack’s “Six point checklist to more discriminating opioid prescribing”
- How definable is the source of pain?
- SCREEN for risk of addiction
- Consider ALL treatment options
- If opioids are prescribed:
- LOWEST Effective dose
- LOWEST number of pills
- Educate on Georgia 9-1-1 Medical Amnesty Law
- EDUCATE the patient
- Risks / benefits of opioid use
- Sharing opioid medications is illegal
- Proper storage / disposal
- MONITOR the patient for misuse / diversion
- Prescription Drug Monitoring Program
- Controlled substances agreement
- Drug Screening / pill counts