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- Opioid Classification
Although the term opiate is often used as a synonym for opioid, the term opiate is properly limited to the natural alkaloids found in the resin of the opium poppy (Papaver somniferum). The opium poppy was cultivated as early as 3400 BC in Mesopotamia. The term opium refers to a mixture of alkaloids from the poppy seed. Opiates are naturally occurring alkaloids such as morphine or codeine. Opioid is the term used broadly to describe all compounds that work at the opioid receptors. The term narcotic (from the Greek word for stupor) originally was used to describe medications for sleep, then was used to describe opioids, but now is a legal term for drugs that are abused as well. OPIOID CLASSIFICATIONS Most opioid medications are in the oral formulation but some of the opioids do come in a patch option. The two most common used opioid patches currently include the fentanyl patch and the buprenorphine patch, also known as the Butrans® Patch. Extra caution should be taken with thOccurringe use of the Fentanyl patch in the elderly and is contraindicated in the opioid-naïve patient (patients who are taking less than 60mg of morphine equivalence daily). Fentanyl patches are advantageous in patients who are unable to swallow pills. The disadvantage with fentanyl patches is their delayed onset of action and being highly proteinbound they increase the risk of overdose in frail patients (decreased plasma protein resulting in higher free fentanyl levels combined with the reduced ability to metabolize fentanyl). As body temperature increases, the absorption of the drug can increase, and therefore may be problematic with febrile patients or those who use heating pads, etc. Once the patch is removed, the time to drug elimination is significantly longer (>24hours) in the elderly patient. These patches also have a higher risk of skin rashes which can be very uncomfortable for the patient who have sensitive skin. An alternative to the Fentanyl patch is the Butrans® Patch, which contains the medication buprenorphine. These patches have the advantage of being better tolerated in elderly patients and a decrease risk of over sedation and other side effects. They also can be used in opioid naive patients. They are good options when strong opioids are undesirable. They also have lower abuse potential and milder withdrawal symptoms. In elderly patients, buprenorphine patches may have altered pharmacokinetics due to poor fat stores, muscle wasting or altered clearance; therefore they should be used with caution with skinny patients. Patients on high doses of morphine and/or strong opioids should NOT be switched to transdermal buprenorphine due to its potential to precipitate opioid withdrawal. The Butrans® patch also has similar concerns of a skin rash and increased absorption of the drug with higher body temperature as does the fentanyl patch.
- Safety
Opioid related deaths have been a hot topic recently as well as in the past. Their safety and role in the treatment of chronic diseases such as pain as come into question. However, studies over the past 20 years have repeatedly shown opioids to be safe when they are used correctly. Multiple studies in the United States and around the world have shown opioids to be a safe and effective treatment option. Risk of opioid therapy also includes physical dependence, tolerance, opioid induced hyperalgesia, and addiction. Often the adverse events related with the use of opioid medications involve over use and often are due to the combination of other “sedative” agents such as alcohol, benzodiazepines, sleep medications and/or other sedative medications. The key point is that yes opioids are safe when USED CORRECTLY but they can be deadly if ABUSED. Please note like any medication, significant side effects such as death have been reported in individuals who take their medications correctly. The KEY to being SAFE is understanding the medications you take. This is why this course is a necessary part for anyone taking these or similar medications. It is important that patients speak to their doctor if they have any questions or safety concerns before starting opioid therapy. Please note there is limited evidence as to the benefits of long-term opioid therapy. It is impossible to tell which patients need low doses and which need high doses, so we recommend that all patients start on low doses, especially those who are new to these medications. Over time if needed your doctor can titrate the dose of the opioid medication to provide more effective pain relief, while minimizing adverse side effects. It is important to understand that the lowest dose needed for effective pain control is recommended. Higher doses do not translate into better pain relief in many cases. Rather than adding high doses of opioids to your treatment plan talk to your doctor about the addition of other treatment options, which are discussed later in this course. Opioid analgesics themselves for the most part do not cause any specific organ toxicity, unlike many other drugs, such as NSAIDs, aspirin and acetaminophen. They are not associated with upper gastrointestinal bleeding and renal toxicity like long term NSAID use. However, we do still recommend annual liver and renal function test from your primary care doctor for patients who are on long term chronic opioid therapy. The metabolism and excretion of these medications are affected greatly by the liver and kidneys. We will discuss more about the side effects of these medications and issues in patients with liver and renal disease later in this course. When using combination opioid products containing acetaminophen, aspirin, or ibuprofen (such as Norco®, Vicodin® or Percocet®), the dose limiting toxicity is generally attributable to acetaminophen, aspirin, or ibuprofen respectively. The maximum amount of acetaminophen should be no more than 4 grams/day considering all combined acetaminophen in 24 hours. Using more than 4 g/day of acetaminophen can cause acute hepatic failure. Aspirin and ibuprofen have their own inherent toxicities, including but not limited to possible gastrointestinal bleeding, kidney dysfunction, hypertension, etc. Maximum daily dose of aspirin is 4grams/day. The maximum daily dose of ibuprofen is 3.2grams/day. For chronic daily use of combination medications I recommend you use the least amount needed and I do not recommend more than 50% of the daily maximum dose of these medications when used chronically (i.e. acetaminophen no more than 2 grams a day). Also if used on a chronic basis routine and annual blood work by your primary care physician is recommended which includes liver and renal function tests. It is important that you report any abnormal lab results to the doctor who prescribes you your opioid medications. It is important for us to note here, regarding senior citizens, opioid use is associated with increased adverse effects such as "sedation, nausea, vomiting, constipation, urinary retention, and falls. As a result older adults taking opioids are at greater risk for injury. We will also revisit this topic at the end of the course. Opioids are well accepted for the treatment of acute pain, such as post-operative pain. They have been extremely valuable in the treatment of terminal disease such as cancer as well as severe degenerative conditions such as rheumatoid arthritis. When used properly they have also found to be an important modality in the treatment of chronic pain. The field of pain management itself also evolved over the decades and now patients with chronic pain are often treated by board certified pain medicine specialists. Current opioids such as methadone should only be prescribed after trying other opioids first due to the higher risk of adverse side effects. Safety concerns with methadone are due to its sometimes unpredictable pharmacodynamics and pharmacokinetics. Methadone is difficult to titrate due to its half-life variability. It may take a long time to reach a stable level in the body. Never ever take more than prescribed when it comes to Methadone, as it can seriously lead to overdose and death. To improve safety always inform your doctor of any change in your health. Inform your doctor if you have or develop COPD, Pneumonia, CHF, sleep apnea, alcohol or substance abuse, are over 65 years of age, have history of or develop renal or hepatic dysfunction. These conditions may potentiate opioid adverse effects and require close monitoring. Even low doses of opioids can lead to more risks than benefits with these conditions. The Basic DOs and DON’Ts of Opioid Safety Call 911 Or Your Local Emergency Service Right Away If: You take too much medicine You have trouble breathing, or shortness of breath A child has taken your medicine Tell Your Healthcare Provider: Your complete medical and family history, including any history of substance abuse or mental illness The cause, severity, and nature of your pain If the dose you are taking does not control your pain • About any side effects you may be having About all the medicines you take, including over-the-counter medicines, vitamins, and dietary supplements Your treatment goals If you have underlying respiratory disease Certain medical conditions such as sleep apnea, pneumonia, COPD, etc. can increase your risk of overdose and respiratory arrest when combined with opioid therapy. If you develop pneumonia you should inform your provider as you may need to consider a reduction of your dose. If you suspect you snore heavily or have day time sleepiness, it is important you discuss with your provider the option of a sleep study to evaluate for sleep apnea and possible use of a CPAP machine.
- Golden Rules Not to Break
As you have already learned opioid medications can improve ones quality of life but these medications are highly addictive and when used improperly can lead to serious consequences such as death. There there are a few GOLDEN RULES that most pain clinics and physicians will expect you to adhere to. Please discuss with your particular physician or pain clinic as to their strict office policies. You should always read fully the treatment agreement provided to you by your clinic. Failure to comply with your treatment agreement will place you at increased risk of adverse events with the use of opioid therapy, such as overdose and death and may subject you to discontinuation of opioid therapy as an option in your treatment plan. DO NOT VIOLATE THE FOLLOWING GOLDEN RULES No Early Refills: NEVER TAKE MORE THAN PERSCRIBED. Always Follow the directions given to you by your provider regarding your medications and that written on your prescription bottle. Discuss with your provider what your options are to treat a pain flare, as overtaking your medication due to pain flare may not be considered a valid excuse. You may be subject to Random Pill Counts by your provider to ensure you are not taking more than prescribed. Cures: Your provider may check the DEA database regularly which lists all opioid medications prescribed. Your treatment agreement will usually state that you can not fill outpatient opioid medications from other outside providers, such as dentist emergency room, surgeons, ETC. Urine Drug Screening: Your provider may check urine drug screens to make sure you are ONLY taking the opioid medications prescribed to you. Never take a friend's medication. Never take old medication even if it was prescribed to you in the past unless instructed by your provider. If you are prescribed an opioid medication that does not show up in a UDS you may be required to provide an explanation. It could be considered a violation without a reasonable explanation for the non-presence of a prescribed medication. 30-Day Refill Policy: You typically are provided a prescription that is to be used over a 30-day period. This may vary from clinic as some clinics write only 28-day supplies, so be aware of how long the prescription you are given is expected to last. If for example you are given a 30-day supply of medications within 28 or 29 days. Due to pharmacy issues and other factors patients may pick up their next prescription on day 28 or 29. If so the expectation is that you Do Not Open The Next Prescription Bottle Until Due ("Day 31"). You are responsible for keeping track of when your next prescription is due and when your next bottle can be opened. Failure to comply and keep track of when you can start your next prescription bottle may be considered a violation your treatment agreement. You may be required by your provider to bring your prescription bottles to each visit to ensure compliance.
- Pain Relief vs. Function/ADL
Your doctor may often ask about changes in your function along with changes in your pain scores throughout your treatment. They may ask you questions in regards to your activities of daily living (ADLs). Activities of daily living is a term used in healthcare to refer to daily self-care activities within an individual's place of residence and/or their outdoor environments. Often patients may report no improvement in pain scores, but when questioned further they will show a significant improvement in function due to the treatments they received. As a patient it is important to evaluate yourself for improvement in function and not just improvement in pain. Increase function can be a goal to focus on when deciding on treatment options to improve your overall quality of life. Having goals relating to increase in function can create more structure to one’s management and justification for use of medications and treatments. Goals that you set should be simple and reasonable, such as being able to complete a favorite hike, being able to take one’s grandchildren fishing, etc.
- Welcome
Opioid therapy – when used safely – can be a very important part of a patient’s treatment plan for chronic non-terminal pain. That being said, opioid medications and medications similar to opioids in the wrong hands and when misused can have deadly consequences. The lack of knowledge about these medications and their appropriate use has often led to a deadly outcome. When used appropriately, they can often help restore one’s quality of life and function. Therefore, knowledge is power; this course was designed to educate not only our patients, but the community and referring physicians alike on the facts and opinions behind opioid therapy. The following course will cover a wide range of issues surrounding these medications. It is important that you complete the course fully. There is an optional section after the course that we recommended you read as well. In order to establish that you have understood the information, you will be given a set of questions to answer. Upon completion of the course you will also be given a printable “Certification of Completion.” We recommend you provide a copy of this certification to your primary care physician and the physician prescribing your medications so they may scan it into your medical records. The benefit to patients who use these drugs correctly is tremendous. Therefore, it is vital that we understand and develop better and safer practices to protect both our patients and the community from the misuse of these medications, or they will no longer be available in the future.
- Introduction
Start off your program by giving some basic information about what participants can expect to learn. Introduce the topic and provide a basic outline of what's to come using videos, images, and text.
- Introduction
Welcome to the online Opioid Safety Course, part of the Online Chronic Pain Education and Prevention Program. Opioid therapy when used safely can be a very important part of a patient’s treatment plan for chronic non-terminal pain. That being said, opioid medications and medications similar to opioids in the wrong hands and when misused can have deadly consequences. Knowledge is power and this course was designed to educate not only patients, but the community and referring physicians alike on the facts and opinions behind opioid therapy. The lack of knowledge about these medications and their appropriate use has often led to a deadly outcome. When used appropriately they can often help restore one's quality of life and function. The following course will cover a wide range of issues surrounding these medications and it is important that you complete it fully. There is an optional section after the course that I recommended you read as well. In order to establish that you have understood the information, you will be given a set of questions to answer. Upon completion of the course, you will also be given a printable “Certification of Completion”. We recommend you provide a copy of this certification to your primary care physician and the physician prescribing your opioid medications.. The benefit to patients who use these drugs correctly can be tremendous. Therefore, it is vital that we understand and develop better and safer practices to protect both the patients and the community from the misuse of these medications or they will no longer be available in the future. As a community let us learn to USE the medications appropriately and not ABUSE them. You will notice a lot of repeated information on this website which was done intentionally to stress the importance of critical information.