Other Considerations

Prescription Drug Monitoring Program (PDMP)

The PDMP is an online tool available to all prescribers, pharmacists, and patients in Oregon. Once a prescriber is registered with the program, he or she can learn exactly which prescription medications a patient has taken and is taking. The value of this information cannot be overstated. We strongly encourage its regular use as an assessment and management tool. Without question, a query of the PDMP should be completed for each patient prior to prescribing. Prescribers can now delegate “look-up authority” to their support staff. Click here for details.

Concomitant Benzodiazepine and Opioid Use

Most experts advise against concomitant use of benzodiazepines and opioids because of the synergistic effect of those drugs in combination exacerbating respiratory depression. As many as 50% of opioid overdoses have involved sedative hypnotics. In addition, the anterograde amnesia that is inevitable with benzodiazepines can contribute to inadvertent overdose for predisposed individuals. It is strongly recommended that you check for benzodiazepine use by UDS, PDMP query, as well as observing for impairment or sedation. Psychotherapy is often helpful as an adjunct to tapering (see Tapering in this document). Some individuals may require inpatient treatment to successfully discontinue use. Many patients who are dependent on benzodiazepines have a difficult time abstaining from other sedative hypnotic substances (such as alcohol, barbiturates, and carisoprodol), and these drugs have similar risks for overdose when combined with opioids.

Concomitant Marijuana and Opioid Use

Medical and recreational marijuana is legal in Oregon and many other states. It is still illegal, however, under federal law. Marijuana is clearly a mind-altering drug, and though it may provide mild to moderate pain relief, it does have associated risks and side effects, such as altered response times, perceptual changes, and mood changes. In some circumstances, marijuana use may be associated with other illicit or risky drug use.

Some providers do not prescribe chronic opioids when marijuana is used (the patient has to choose which treatment modality to use). Others decide not to include THC in their UDS so as not to create a conflict with their patients. Others believe that marijuana may provide appropriate additional pain relief, particularly CBD (cannabidiol) enhanced varieties.

Disposal

The overprescribing of opioids can lead to the accumulation of unused pills in the medicine cabinet. This is true, especially for acute pain situations, when 30 pills may be prescribed for a time-limited situation and only five pills are taken. Those unneeded medications can pose a risk to children or can inadvertently provide a source of illicit opioids through theft or sharing. The ability to safely dispose of unused medication is an important strategy in the fight to reduce unnecessary opioids in circulation.

Drug take-back programs: The Drug Enforcement Administration promotes national drug-take back day on May 8. Many law enforcement agencies have drug drop boxes in their communities. Some pharmacies may also take unused medications as the laws have been relaxed allowing for medication return in some states. The FDA and DEA have useful hints on their websites for disposal, including how to dispose of unwanted medication safely.

Medication-Assisted Treatment (MAT)

Medication-assisted treatment refers to the use of pharmaceutical agents to treat opioid-use disorder. Generally methadone, buprenorphine, and naltrexone sustained release are used for this purpose. Methadone and buprenorphine have the highest rates of success for opioid-use disorder, an important consideration when weighing the significant risks associated with abuse versus the greater relapse rate associated with non-medication treatment regimens. Remember, those with opioid addiction are living with a potentially fatal chronic disease and deserve prompt and effective treatment.

  • Methadone can only be prescribed for addiction treatment in a federally monitored treatment facility. Methadone treatment for chronic pain should be used cautiously, if at all, and only at low doses. Significantly higher daily doses (80–100 mg average) are used when treating opioid-use disorder because the MAT clinic can institute tight medication oversight such as daily nurse monitoring, counseling, UDS, and PDMP query. The use of high-dose methadone in such circumstances does not carry the same degree of risk as it would in a primary-care setting.
  • Any physician in an office setting can prescribe buprenorphine, after taking a brief educational course and getting an “X” waiver added to their DEA number.43 Buprenorphine is safer than methadone and generally more convenient to the patient. It is recommended that if you prescribe opioids for chronic pain, you should either become a buprenorphine prescriber or have ready access to that service.
  • Medication-assisted treatment should be accompanied by ongoing behavioral supports, and it is strongly recommended that providers of care utilize such expertise as a part of their treatment plan.
  • Recognizing opioid-use disorder in your patient should trigger an immediate referral to an effective treatment program or, if you are X waivered, a switch to buprenorphine treatment.
  • Injectable naltrexone can be another useful tool for the patient motivated enough to begin treatment after total opioid abstinence. It also can be provided in a practitioner’s office.

Heroin

There has been a rise in heroin use, heroin overdoses, and heroin treatment admissions in the U.S. over the past decade.44 Opioid dependency does not differentiate between mu agonists, so individuals who develop a substance-use disorder with prescription opioids will find symptomatic relief with any opioid, including heroin. In many parts of the country, heroin is cheaper than pills and is accessible almost everywhere. Therefore, many individuals who cannot stop using pain medications because of dependency or addiction, and whose demand exceeds their supply, turn to heroin use.

Heroin can be smoked, snorted, or injected. It comes in various forms: black tar, gunpowder, and white powder. The potency of the drug varies both regionally as well as temporally, making dosing decisions on the part of the user difficult and dangerous. Overdoses are common, particularly when an addict has reduced his or her tolerance (jail, prison, sobriety based on residential treatment) and then resumes use. Concomitant
use of sedative hypnotics such as alcohol, benzodiazepines, carisoprodol, and sleeping pills increase the risk of overdose.

The most effective treatment for heroin addiction (as well as all opioid substance-use disorder) is medication-assisted treatment (see the MAT section in this document). Since discontinuation of opioids leads to reduced opioid tolerance, relapse is associated with an increased risk of overdose. Risk of relapse and overdose should be an educational component to all opioid treatment.

Bystander naloxone is an essential “downstream” treatment that reduces mortality from opioid overdose. See the Naloxone section (below) in this document.

Individuals with a history of heroin use, past or present, are at high risk of inappropriate use of prescription opioids. Such individuals can safely be treated using buprenorphine or methadone, and primary-care or pain-specialty providers need to be very cautious treating such individuals for pain using opioids.

Naloxone

Naloxone is a pure mu antagonist, and as such, it is an antidote to the effects of opioid intoxication. It reverses respiratory depression that is the cause of death in an opioid overdose. Naloxone has essentially no adverse effects and is remarkably successful in reversing the life-threatening effect of opioids. The incidence of opioid overdose is dose related, but anyone taking opioids is potentially at risk. Therefore, we recommend co-prescribing naloxone for the families and loved ones of all patients prescribed opioids for chronic use.

Naloxone displaces other opioids off the mu receptor sites, but it has a short half-life, having an effect for 30 to 90 minutes. After the drug wears off, the agonists may again reattach to the receptors. Anyone requiring naloxone treatment should be transported to an emergency department for further evaluation since return to the overdose state is possible with the passage of time after the initial naloxone treatment.

Naloxone can be administered parenterally (IV or IM), but it is also effective as a nasal spray. The drug has a very rapid onset of effect when given IV. Its onset of action is more gradual, but still lifesaving, when given via intra-nasal spray. Lay persons can easily be trained to use the intranasal product.

Naloxone is a drug administered by another person to rescue an individual who is overdosing on an opioid. Friends or relatives are often the ones who are present at the time of an overdose and are therefore the individuals who need to receive naloxone training.

Naloxone co-prescribing

Everyone taking opioids on a daily basis should have their friends or loved ones trained in naloxone use. It should be a part of a routine prescribing protocol for prescribers. It communicates your concerns about safety to your patient.

Many states allow lay-person use of naloxone, many insurance companies will pay for the drug, and in Oregon, a simple online training course will suffice to allow dispensing of the drug.

In 2014, 52 people died every day in the United States from prescription-opioid-related overdoses. Cities and states with naloxone distribution programs have seen 37–90% reductions in overdose deaths. Co-prescribing naloxone with medications is an important component of opioid therapy. Patients and their providers commonly underestimate the chance of experiencing an overdose. “Risky drugs, not risky people” is a useful phrase to use when explaining the necessity of naloxone co-prescribing to patients.

Overdose risk factors

As was stated earlier, all individuals taking opioids are at some risk of an overdose. Certain factors will increase that risk:

  • Individuals taking sedative-hypnotics (alcohol, benzodiazepines) in addition to opioids are at increased risk. Such individuals may have a partial response to naloxone, since the drug only acts to reverse the opioid component of the overdose.
  • Individuals whose opioid tolerance has decreased are at risk. This includes people who leave residential addiction-treatment programs or are released from incarceration.
  • Individuals whose dose of opioids is suddenly increased are at risk. For example, a sudden increase in opioid dosing or a new source of herointhat is stronger than the user expected could result in overdose.
  • Someone who has previously overdosed is at risk of overdosing again.

Further resources

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