Mrs. Wright is a 65-year-old woman with a past medical history that includes:
- Chronic low back pain
- Chronic kidney disease
At home, she takes the following medications (in addition to other medications she takes for her other conditions):
- Opioid pain medications
In addition, Mrs. Wright recently was hospitalized for surgical repair of an ankle fracture. Her pain was appropriately managed during her stay and she is now ready for discharge.
The inpatient anesthesia pain attending physician, Dr. Sellers, is following up to make sure Mrs. Wright understands the risk of opioid pain medications, especially with concurrent use of benzodiazepines, other potential drug-drug interactions, and to answer any other questions or concerns the patient may have.
Dr. Sellers Checks on Mrs. Wright
Prescription Drug Monitoring Program
A prescription drug monitoring program, or PDMP, is a state-wide electronic monitoring database which collects design data on substances dispensed in the state. The PDMP is housed by a specific statewide regulatory, administrative, or law enforcement agency.
The housing agency distributes data from the database to individuals who are authorized under state law to receive the information for purposes of their profession. The DEA is not involved with the administration of any state PDMP.
There are some benefits of the PDMP. As a tool it is used by states to address prescription drug abuse, addiction, and diversion. It may serve several purposes such as:
Support access to legitimate medical use of controlled substances.
Identify and deter or prevent drug abuse and diversion.
Facilitate and encourage the identification, intervention with and treatment of persons addicted to prescription drugs.
Inform public health initiatives through outlining of use and abuse trends.
Educate individuals about PDMPs and the use, abuse and diversion of and addiction to prescription drugs.
Test Your Knowledge
Why would you want to use the PDMP?
Mrs. Wright's Reaction To Dr. Seller's Explanation of the PDMP
Mrs. Wright wants to know what other medications may interact with her prescription opioid medications.
There are many different medications that can interact with your opioid medicines:
- Muscle relaxants
- Neuroleptic or anti-psychotic medications
- Sleep aids
- Neuropathic pain agents
- Other sedating medications
The interactions of the medications with opioid medications can cause confusion and can worsen nervous system depression and respiratory depression effects of opioids.
Benzodiazepines and opioids seem to be the most likely combination to cause the worst central nervous system and respiratory depression.
In response to this public health crisis, the CDC became involved and released the 12 guidelines for prescribing opioids for chronic pain in March 2016.
The CDC wanted to ensure that clinicians and patients consider safer and more effective treatment. These guidelines were released as voluntary recommendations and not standards of care.
The actual guidelines are very detailed at 50 pages. Access the CDC Guideline for Prescribing Opioids for Chronic Pain.
Essence of CDC Guidelines
- The CDC guidelines do not relate to active cancer treatment, end of life or palliative care or hose patients who are institutionalized.
- The focus before starting opioids is on the risk the medication poses to the patient.
- First and foremost, all non-opioid pain treatment options should be exhausted.
- Verify opioid prescriptions using the Prescription Drug Monitoring Program (PDMP) searches.
- Do not prescribe opioids concurrently with benzodiazepines. (Do not mix with other depressants.)
- Patient's risk for adverse events increase at greater than 50 (MME)/day.
- If that dose must be exceeded, the patient must be counseled on the increased dose and use of a naloxone injector. Patients are at the greatest risk when taking greater than 90 (MME)/day.
- Do not exceed 90 (MME)/day if at all possible.
- Limit the duration of opioid treatment to the least time possible.
The CDC noted that in about half of overdose deaths caused by opioids, another type of drug acted as a contributing factor. Benzodiazepines like valium and Xanax were found most frequently in about 17% of the cases. This deadly combination leads to two primary problems:
- Depressed breathing. This condition leads to a lack of oxygen to the brain, eventually shutting down vital organ systems, leading to brain damage and even death.
- Enhanced sedation, or the inability to wake up or respond to stimuli. This can put individuals at risk of falling if they're standing up or causing a serious car accident if they're driving. People could also slip into a coma.
These issues can both cause death if emergency medical assistance does not come in time.
Clinicians should avoid prescribing opioid pain medications and benzodiazepines concurrently whenever possible. Clinicians should communicate with others managing the patient to discuss the patient's needs, prioritize patient goals, weigh risks of concurrent benzodiazepine and opioid exposure and coordinate care.
Patients' risk for adverse events increase at greater than 50 (MME)/day and even higher beyond 90 (MME)/day. If these doses must be exceeded, the patient should be counseled on the increased dose and use of a naloxone injector.
Naloxone is an opioid antagonist that can reverse severe respiratory depression. Its administration by laypersons, such as friends and family of persons who experience opioid overdose can save lives by providing a gateway to ongoing medical care.
Test Your Knowledge
Concurrent use of opioids and benzodiazepines is commonly associated with which of the following side effects? (Chose all that apply.)
Mrs. Wright Decides to Try Wean Herself Off of Some Medications
Mrs. Wright wants to know about some non-opioid treatment options for her pain.
The CDC recommends that people who take opioids consider:
- Physical therapy
- Non-opioid medications such as acetaminophen or ibuprofen
- Topical medications
- Cognitive behavioral therapy
- Regional anesthesia like nerve blocks
These options should be used to help manage pain while minimizing opioid use.
The CDC offers more information for patients on its website. You can also discuss other resources with your primary care physician and pain physician.
Test Your Knowledge
What modalities are available to treat pain and anxiety, other than opioids and benzodiazepines? Select all that apply.
Next Steps for Mrs. Wright
Mrs. Wright is encouraged by Dr. Sellers to discuss with her primary care physician and pain physician before tapering any of her medications.
The clinical opiate withdrawal scale (COWS) is a useful tool to help rate concerning symptoms of opioid withdrawal. Symptoms include:
- Dilated pupils
- Increased pain
Mrs. Wright's Concerns About Naloxone
Mrs. Wright asks about Naloxone and whether Dr. Sellers thinks she may overdose. Dr. Sellers tells Mrs. Wright she's not concerned about her intentionally harming herself. She lets Mrs. Wright know that sometimes people accidentally take too much of opioid medicines, especially if they're taking opioids and benzodiazepines together. People like Mrs. Wright are given the prescription for Naloxone to help keep them safe in an event like this.
Naloxone is a safe and effective treatment to reverse the respiratory depressant effects of opioids.
The CDC recommends that physicians consider offering Naloxone if a person has a history of opioid overdose, history of substance use disorder, higher opioid dosages of greater than or equal to 50 (MME)/day, or concurrent benzodiazepine use.
Test Your Knowledge
All of the following are potential reasons to consider offering Naloxone, EXCEPT:
Mrs. Wright understands about the need to prescribe Naloxone to go along with her other prescriptions of opioids and benzodiazepine. She tells Dr. Sellers about her neighbor's grandson:
"My neighbor's grandson died after an Oxycodone overdose. He was a bright boy and it was so sad to watch him get sick with his addiction, and then devastating when he died. I'm sure his family would've done anything to keep him alive, give him time to get better."
Dr. Sellers says, "Oh wow. How did he get into this in the first place?"
Mrs. Wright responds, "He was stealing medicine out of his grandmother's medicine cabinet."
"That is so sad," Dr. Sellers says. "It's actually something we're trying to prevent from happening again in the future. Really, it's affecting so many people. You just never know."
"Now, what other questions do you have, Mrs. Wright?" Dr. Sellers asks.
"I don't think I have any, at least not right now," says Mrs. Wright.
Dr. Sellers tells Mrs. Wright, "Next, I'm going to call your outpatient pain doctor, Dr. Smith, to tell him about the change we made in your home opioids due to the extra pain you were having with the surgery and the ankle fracture. It's also to let him know what you and I have discussed about keeping you safe with these medications."