Kentucky is one of the states most heavily affected by the opioid epidemic. The National Institute on Drug Abuse (NIDA) reported, “In 2017, there were 1,160 reported opioid-involved deaths in Kentucky—a rate of 27.9 deaths per 100,000 persons, compared to the average national rate of 14.6 deaths per 100,000 persons.”1 While most of these deaths are related to synthetic opioids, prescription opioid related deaths have remained at high, steady rate over the years.1
NIDA reported, “Kentucky is among the top 10 states with the highest prescribing rates.1 In 2017, Kentucky providers wrote 86.8 opioid prescriptions for every 100 persons compared to the average U.S. rate of 58.7 prescriptions.”1 While the rate of opioid prescriptions being written has decreased since 2011, the number of deaths is still increasing as reported by NIDA.1
Let’s start with what an opioid is...
Opioids are a class of drugs that are produced by the opium poppy plant. There are many different drugs that are in the opioid class, but they all have a sedative and analgesic effect. While opioids are a potent “pain-killer” and sedative, they can also produce a relaxed conscious state. This feeling of relaxation is enticing to individuals which can lead to addiction.2
Morphine is a commonly used opioid, especially in the hospital setting. Morphine is the opioid to which other opioids are compared. Morphine works on the kappa, delta, and mu opioid receptors.3 The “pain-killing” effect that is produced by morphine binding to mu opioid receptor which is located in the central and peripheral nervous systems.3 The mu opioid receptor is also expressed on respiratory stimulating neurons in the brain stem; this means the sedative effects of morphine can cause respiratory depression that can lead to death.4
So, you may be asking what led to this opioid epidemic of death and addiction? While there are many factors, one of the most commonly discussed in the healthcare community is the Pain as the 5th Vital Sign campaign that started in 2001 by the Joint Commission.5 This campaign was to help healthcare professionals assess and treat pain better. Although, in 2016, the Joint Commission formed a panel to review their guidelines and previous recommendations.6 They reported that while it is important to assess and treat pain, “an inter-professional team approach to implementing multi-dimensional pain assessment tools in clinical practice is therefore needed.”6
Given the life-threatening, additive properties of opioids, health care providers are moving towards “opioid sparing analgesia” and “multimodal analgesia.” The American Association of Nurse Anesthetist and the American Society of Anesthesiologists recommend to treat pain with opioids and non-opioids if appropriate; meaning, some patients may not even require opioids for their pain control. They state, “using opioids alone may adversely affect the patients postoperative recovery...combining opioids with non-opioids creates a synergy that magnifies the analgesic effect of each.”7
Non-opioid medications that can be used alone or in conjunction with opioids for analgesia are non-steroidal anti-inflammatories such as ibuprofen and ketorolac, and acetaminophen. Ketorolac and acetaminophen are available in the intravenous form which makes it easy to give in operative stages or if a patient cannot eat.7 Non-opioid drugs that can be used for sedation purposes that are intravenous ketamine and dexmedetomidine. While every drug has side effects, none of the previously mentioned drugs lead to respiratory depression if properly administered.7
A recent study showed that patient satisfaction was just as high if not better when patients were given non-opioids such as ibuprofen and acetaminophen for their post operative period.8 The participants reported little to no opioid use and still were able to complete their activities of daily living which shows that non-opioid analgesia can and does work for most individuals.8
More invasive yet reportedly helpful forms of pain control for patients using the opioid sparing techniques are radio frequency ablation of the involved nerve/s and nerve blocks that involve injecting a numbing agent into the affected area.9 Patients also report positive results from transcutaneous electrical nerve stimulation that interrupts the nerve signals, and spinal cord stimulation that can help with lower back pain.9 Other interventions include: acupuncture, physical therapy, and more studies are being done on the use of cannabidiol and stem cell injections.9
References
- 1. Kentucky Opioid Summary. (2019). Retrieved 14 October 2019, from https://www.drugabuse.gov/opioid-summaries-by-state/kentucky-opioid-summary
- 2. Butanis, B. (2019). What Are Opioids?. Retrieved 14 October 2019, from https://www.hopkinsmedicine.org/opioids/what-are-opioids.html
- 3. Pathan, H., & Williams, J. (2012). Basic opioid pharmacology: an update. Retrieved 14 October 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590096/
- 4. Boom, M., Niesters, M., Sarton, E., Aarts, L., Smith, T., & Dahan, A. (2012). Non-analgesic effects of opioids: opioid-induced respiratory depression. - PubMed - NCBI. Retrieved 14 October 2019, from https://www.ncbi.nlm.nih.gov/pubmed/22747535
- 5. Baker, D. (2017). The Joint Commission's Pain Standards: Origins and Evolution.
- Retrieved 14 October 2019, from https://www.jointcommission.org/assets/1/6/Pain_Std_History_Web_Version_05122017.pdf
- 6. Scher, C., Meador, L., Van Cleave, J., & Reid, M. (2018). Moving Beyond Pain as the Fifth Vital Sign and Patient Satisfaction Scores to Improve Pain Care in the 21st Century. Retrieved 14 October 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878703/
- 7. Vo, B., Clayton, E., & Stolyarskaya, J. (2018). Opioid and non-opioid analgesia during surgery - American Nurse Today. Retrieved 14 October 2019, from https://www.americannursetoday.com/opioid-non-opioid-analgesia-surgery/
- 8. Hallway, A., Vu, J., Palazzolo, W., Waljee, J., Brummett, C., Englesbe, M., & Howard, R. (2019). Patient Satisfaction and Pain Control Using an Opioid-Sparing Postoperative Pathway. Retrieved 14 October 2019, from https://www.ncbi.nlm.nih.gov/pubmed/31154092
- 9. Non-Opioid Treatment for Chronic Pain - When Seconds Count. Retrieved 14 October 2019, from https://www.asahq.org/whensecondscount/pain-management/non-opioid-treatment/
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ReplyDeleteGreat post! This is a huge problem we should all care more about fixing. I am thinking of potential solutions to combat opioid abuse as well as the negative side effects of their use. PZM21 is a drug that comes to mind as a good option. PZM21 is an experimental opioid analgesic; it is a functionally selective μ-opioid receptor agonist, which produces μ-opioid receptor mediated G protein signaling, with potency and efficacy similar to morphine, but with less β-arrestin 2 recruitment. β-arrestin 2 is crucial for the development of tolerance to morphine and other opioids. In animal models, PZM21 caused analgesia but did not promote respiratory depression or place preference. I think the burden of opioid dependency needs to be tackled by providers and patients alike. A system where expectations of scripts as the basis for satisfaction only works to perpetuate this problem; more drugs like PZM21 will need to be developed along with a change in how we think about pain management will need to occur before we can lessen the impact of addiction (1).
ReplyDelete1. Manglik, Aashish et al. “Structure-based discovery of opioid analgesics with reduced side effects.” Nature vol. 537,7619 (2016): 185-190. doi:10.1038/nature19112
Great article! I think it is important to stress that some people may not require opioids for post-operative pain. Researching opioid-sparing analgesia is a great way to help prevent opioid dependency that could lead to addiction in patients. I have lived in KY my entire life, but I never realized how much greater the opioid crisis in KY was compared to the national average. Since this was an alarming fact, I researched the opioid crisis in KY further. I found that in 2012, KY passed legislature to help decrease the total number of prescription opioids. Since then, opioid analgesic abuse has decreased but heroin use has increased. This raises an important question about how to decrease prescription opioids without turning people dependent or addicted to opioids to more dangerous and possibly laced opioids. Great job!
ReplyDeleteVictor, G., Walker, R., Cole, J., & Logan, T. (2017). Opioid analgesics and heroin: Examining drug misuse trends among a sample of drug treatment clients in Kentucky. International Journal of Drug Policy, 46(C), 1-6.
Its important for all pharmacists, clinicians and policy makers to know the real issue and root cause for pain management and addiction. There is a huge stigma and a rising prevalence of addiction rates in opioid users. The Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS), approved in September, is FDA’s latest strategy to reduce the risk of abuse, misuse, addiction, overdose, and deaths due to prescription opioid analgesics. This new plan includes several measures to improve training of health professionals on the use of opioid pain medications and their serious risks. This strategy can reduce the misuse and overdose of these addictive medications and can provide patients and clinicians a way to control the use over a period of years. FDA has determined that provider training through REMS is necessary for all opioid analgesics intended for outpatient use. Extended-release and long-acting (ER/LA) opioid analgesics have been subject to a REMS since 2012, as well as the entire class of transmucosal immediate-release fentanyl prescription medicines since December 2011. The expanded REMS is the first to apply to immediate-release (IR) opioid analgesics intended for use in an outpatient setting.
ReplyDelete“More Training Included in New REMS for All Outpatient Opioids .” Home, 19 Nov. 2018, https://www.pharmacist.com/article/more-training-included-new-rems-all-outpatient-opioids.
Great post! I am glad that you looked into a study where people had non-opioids and it worked out well for them. This is a very important point in opioid research because then there is no reason left to argue that the use opioids are better than non-opioids. I understand that there are some cases in which the use of this opioids might be needed, but I believe if that is absolutely necessary then it should be under supervision and not prescribed for use outside of a medical facility.
ReplyDeleteFor the betterment of all, I strongly think that pharmacists, doctors, and scientists should work together and create a better replacement than opioids. There have been absolutely too many failed attempts to correct the issues with opioids over the decades.
Interesting read! I appreciate you focusing on this issue because like you mentioned, this is huge problem especially in Kentucky. We should definitely be concerned. I also like that you provided alternatives as well as stating that patients reported being just as satisfied when administered acetaminophen and ibuprofen. I think it is important for physicians to be cognizant about how often they prescribe opioids because it can lead many people down a dangerous path. Also, what do you think about having a patient database that all physicians can access? A problem that I have noticed is that a patient will get prescribed opioids by several physicians which I believe can be avoided if all physicians are aware of the medications a patient has been prescribed or has been taking. I understand that this may not be effective or even pose a lot of issues in terms of patient confidentiality and privacy. But, I can't help but wonder what can be done to solve this because it is incredibly sad.
ReplyDeleteVery interesting and informative post. The opioid epidemic is certainly a major socio-economic crisis that must be addressed. I find topics like this to be very thought-provoking. As you mentioned, many patients can remain comfortable postoperatively without the use of opioids and yet there are some cases for which their use may be warranted. The need and want of opioids are clearly being undermined. The big question is, will there be uniformity in who decides which patients could safely benefit from opioid use and which patients should be managed otherwise? Who is going to force physicians to stop prescribing these drugs? There will always be a select pool of physicians who, regardless, will feed the epidemic. As you mentioned, the bottom line is that if we can manage pain through alternate, non-addictive, methods then we may be able to reduce the incidence of opioid related deaths.
ReplyDeleteJen Eccleston
This post shed some very interesting information about opioid-sparing pain management. It was very interesting to learn how the use of the listed drugs have show the ability for clinicians to now use the non-opioid analgesics (NSAIDs). In the past few years the scientific community has learned that opioids indeed are the mainstream to help with pain control and for pain management. However, this has lead to the wide use of prescribing drugs to help with pain management, which in turn creates a dependence and issues with opioids. It was very interesting to read and understand that acetaminophen is a common used analgesic and antipyretic drug that is safe for non-opioid analgesia. An interesting study by Gharibo et al, show that drugs such a indomethacin (NSAID) can help with providing opioid-sparing effects when combined with multiple analgesia drugs.1 The study found that there is a drastic reduction in number of patients that needed opioid rescue medication and the use of indomethacin is promising.1 It was found that the use of “SoluMatrix” indomethacin there is a reduction in the need for opioids to help manage pain and show less dependence of opioids.1 Thus, this supports and shows that the use of indomethacin or NSAIDs can improve management of pain and reduce reliance of opioids.
ReplyDelete1. Gharibo, Christopher G., et al. "Opioid-sparing Effects of SoluMatrix Indomethacin in a Phase 3 Study in Patients With Acute Postoperative Pain." The Clinical journal of pain 34.2 (2018): 138-144.
Great insight on a major topic! It is interesting that a big "boom" in this epidemic can be somewhat linked to the Joint Commission in 2001 as you mentioned. As a life-long Kentucky resident I have witness first-hand just how prevalent of an issue the opioid crisis is. On the contrary, I have also seen patients living with unbearable pain that only opioids seem to effectively control. Non-opioid treatments such as anti-inflammatories and local nerve blocks are not bad alternatives, but certainly to solve this issue we need to better understand pain perception and likely develop a drug with similar functional properties of opiates, without the negative disadvantages; and as you also mentioned, research into the cannabinol system and stem cell therapies may be our key to ending the war on opioids. Great post!
ReplyDeleteYour topic is very compelling because of the prominent opioid epidemic in our area. Your fact regarding how patients were just as satisfied when they were prescribed ibuprofen or acetaminophen makes me question why physicians prescribe opioids so often. I found a study that you may find interesting; it examines epidemiology of the heroin and fentanyl overdoses in Kentucky. The study was conducted because of the increase in fentanyl and heroin overdoses in Kentucky from 2011-2015. The study found that most of the opioid overdose cases had histories of being prescribed opioids in substantial quantities. This study recommended that as a society, we should collectively transition from being reactive when overdoses occur to being more proactive (Slavova et al. 2017). From what we learned in class regarding how addictive opioids can be, we know that even the cancer patients that are often prescribed opioids become addicted to these medications. Finding a new form of a pain medication that is as effective as most opioids, but without the addictive side effects is in a high demand. Overall, your blog post was very interesting and very well written! I am glad you chose a topic that is so prominent in the area that we live in.
ReplyDeleteSlavova, S., Costich, J. F., Bunn, T. L., Luu, H., Singleton, M., Hargrove, S. L., … Ingram, V. (2017, August). Heroin and fentanyl overdoses in Kentucky: Epidemiology and surveillance. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28735777.
Since 2017 the opioid epidemic has been declared a public health emergency in the United States, so this is a very important topic to address and I am glad you decided to write your blog post on possible alternatives to opioids. What many people do not know is that almost thirty years ago, pharmaceutical companies guaranteed physicians and other medical professionals that opioid pain relievers would not be addictive to patients. Since this claim was made by pharmaceutical companies in 1999 there has been influx of opioid prescriptions by over 400%, as well as, an increase in addicted patients. Over 80% of people addicted to synthetic opioids were first hooked by opioids prescribed by a physician. I think it is vital that physicians look to alternative interventions, such as those you are suggesting, in order to prevent the opioid epidemic from growing. Before reading your post I never realized how many potential alternatives were available to treat pain.
ReplyDeleteU.S. Department of Health and Human Services. (2019, September). What is the U.S. Opioid Epidemic? https://www.hhs.gov/opioids/about-the-epidemic/index.html.
Very interesting post. I liked how you pointed out the benefits of usage of opioids with non-opioids. I believe combining the two in the postoperative setting would lead to a lower dose ever needing to be taken by the patient. I also believe more research toward cannabis and its effect on CB1 receptors, that are closely aligned with mu opioid receptors that are targeted my morphine would be a logical step toward combating this epidemic.
ReplyDeleteCody R
DeleteHello Allison, your blog is an excellent reflection on the opioid crisis. It is truly difficult to imagine the circumstances that made this crisis as severe as it is and it is more difficult to think of a solution that can solve the problem. It is not possible to simply withdraw and stop using opioid drugs and yet it seems unlikely that the volume of prescribed opioids has not increased in a way that reflects legitimate use. Could it be that over-prescription is a part of the problem? I think so, however I also believe that many of the factors that contribute to the formation of abuse and addiction stem from patient pain not being taken seriously by physicians. It is then that alternative routes of procuring drugs and alternate drug forms like heroin are used. Similarly, physicians over-prescribing the drug exposes patients to the incredible addictive potential of opioids and spreads addiction as well.
ReplyDeleteAt the same time, it is important to seek out and explore the possible replacements for opioids as you state in your blog. There is no denying that opioids are some of the most potent and sought after drugs for managing and preventing unpleasant pain and sensations associated with surgery and chronic pain conditions. Surely it would not be possible to get addicted to a drug if the patient is never exposed to it in the first place so substituting pain drugs could mitigate the effects of addition in the opioid crisis. The results you mention speak for themselves, that ketamine, dexmedetomidine, ketorolac, acetaminophen, and ibuprofen can be efficacious in surgical applications and aftercare. I wonder how many alternatives will be explored and found in the future.
I appreciated this blog post bringing to light the seriousness of the opioid epidemic we are currently facing. It is important as a prescriber to be aware of how addicting these drugs can be. I think it is a great step in the right direction to not prescribe an opioid for every patient coming out of surgery. Every patient is different, regardless of if the received the same surgery or not. Which is why every patient's treatment plan should be altered accordingly. If a patient had a minimally invasive surgery, opioids may not be indicated, especially if there is a family history of abuse. However, I have seen first-hand the problems that have resulted from the government getting so heavily involved in prescriptions of opioids. My mother has been a primary care physician for 25 years. I worked at her office as a medical assistant for 2 years and saw a few patients of hers who were prescribed opioids for chronic pain. These patients have been on these medications for 20+ years. Within the last two years, government regulation has required them to now come in to their primary care doctor to be seen for their condition every single month and only then can they receive a refill for their medication. I can see the intent in this new law, however, it causes a lot of issues as well. These patients on opioids for chronic pain often don't drive anymore because of their condition making transportation to and from a doctor's office monthly a bit difficult. On top of this, these patients have been on these mediations for so many years, you would think that the law would be slightly different for long term patients such as the. And lastly, because of these new regulations, many private physicians have opted out of prescribing opioids altogether, whether their patient genuinely needs it or not. It requires far too many hoops for these already overworked physicians to jump through and does a disservice to the patients who need it most.
ReplyDelete-Alivia Larkin
This is a great blog post and definitely something that hits right at home for me! I am from eastern Kentucky, specifically Greenup county. Opioid abuse is a very prevalent issue in that region, and it is not given the exposure it needs. Many people do not understand that opioids are not the premier option for pain treatment, as you discussed many non-opioid options exist that do the job just as well if not better than the opioids do. In conjunction with the research you have done, I found a research study preformed observing the effectiveness of alternatives to opioids and how it affected patients who were addicted to them. This study is vitally important to the future of prescription medicine. This is because opioids will become more and more niche as their effects can be mimicked by many different, less addictive alternatives.
ReplyDeleteDennis BB, Naji L, Bawor M, et al. The effectiveness of opioid substitution treatments for patients with opioid dependence: a systematic review and multiple treatment comparison protocol. Syst Rev. 2014;3:105. Published 2014 Sep 19. doi:10.1186/2046-4053-3-105
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4171401/
Very interesting post! I loved reading a summary of this issue in one place after learning about it in class. I never really knew the extent of the problem until I started reading material like this. Before, I had read short blurbs about this issue within the veterinary field, which explained that doctors are having a hard time obtaining supplies for the medications we use frequently in the field. The most common medications we use are similarly mostly for surgical patients, which include hydromorphone, morphine, fentanyl, hydrocodone and oxymorphone. At my personal clinic, we use hydromorphone very frequently for our surgical patients. It’s always something that we are able to use for difficult or complicated circumstances to make the process go much smoother. I have also witnessed the stress and discomfort that occurs within the staff when hydro is not available for some reason. While the opioid crisis is a very important issue, I feel most people don’t really think of it impacting the veterinary field. However, there has been just as much of an alarm for us as the human medical field. Especially with the occurrence of owners inflicting injuries on their animals in hopes a veterinarian may prescribe them an opioid that they can use for their own addiction.
ReplyDeleteSince this is such a prevalent issue in our area, I think it is also important to know that legislators and providers have also been working together to help reverse the problems they have created. There are now Good Samaritan laws in several states, including Kentucky, which improves access to Naloxone, the life-saving drug that reverses overdoses. There is also a law that helps limit criminal liability for those involved in drug-taking activities when they are involved in helping to rescue a person who is overdosing. This clearly only addresses a portion of the problem, but I find it heartening that both providers and law makers are attempting to rectify this problem. It will take solutions from many directions to fully combat this issue, and I hope in time we will reduce harm that has been done by this opioid epidemic.
ReplyDelete“Reverse Overdose to Prevent Death.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 20 Sept. 2019, https://www.cdc.gov/drugoverdose/prevention/reverse-od.html.
Well done! I love the background on how the epidemic started. It shows that the motivation for opioid use was to bolster pain management techniques, which opioids can certainly do, but it seems like it did this so well that they replaced other medications as the primary pain-treatment technique. Sometimes the prescription of opioids - for example, after a surgery - seem almost impetuous. I know of instances where patients received a prescription of 30 opioid pills following surgery, returned for the post-op checkup 24 to 48 hours later and were asked if they need more, which to me seems absurd on so many levels. I think the opioid-first pain management strategy after surgeries or procedures along with over-prescribing are 2 very big contributors to the epidemic we see today.
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DeletePersonally, I have undergone many surgeries and am very interested in using opioids post-surgical procedure. This question of whether patients need opioids or not after surgery should be greatly considered. Many patients have become addicted once prescribed opioids. From personal experiences, I have not used opioids after my 7 surgeries. The reason I have not used only NSAIDS is because I had nerve blocks. For every surgery I had long-term nerve blocks and by the time the nerve block wore off I was able to handle the pain. I asked Dr. Blalock about this and he mentioned that this all depends on the type of surgery one is undergoing. I have only undergone orthopedic surgeries where the doctor wanted me back to normal as soon as possible. But if an individual went through a procedure where the surgeon needed to crack their breast bone, one would think that an opioid is needed.
ReplyDeleteThe opioid addiction crisis raises many questions and possible solutions to limit the amount of addiction that comes out of surgeries. One of many problems is chronic pain. A patient that suffers from constant and chronic pain will do almost anything to feel no pain. The thought of “killing” nerve ends seems drastic but I have seen from friends and family that it works. Within 24 hours of receiving this procedure I have seen patients up and about walking around like they had no pain.
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