AMA webinar spells out 8 ways physicians can curb opioid misuse

If physicians follow eight rules when prescribing opioids to a patient, they can minimize the potential for prescription drug misuse and help reduce the rising number of unintentional overdose deaths associated with pain medications.

“We need to stop what we’ve been doing the past two decades and have a paradigm shift in the way we are using, prescribing and thinking about opioids,” American Academy of Pain Medicine President-elect Lynn R. Webster, MD, said at an American Medical Association-hosted webinar Nov. 1.

Opioids play a role in 15,000 deaths annually and account for more than 340,000 emergency department visits each year. When Utah physicians followed these guidelines that the AAPM endorses, the state saw a 28% decline in opioid-related deaths.

In the webinar, Dr. Webster outlined eight steps that physicians should follow to combat opioid abuse:

• If a patient develops an upper respiratory infection, asthma or other respiratory problem, the opioid dose needs to be reduced, because opioids can induce respiratory depression. Otherwise, Dr. Webster said, a patient might not wake up.
• Physicians need to assess a patient to determine the risk for opioid abuse. This includes: looking at biological risk factors such as gender (males are at higher risk for abuse) and family or personal history of substance abuse; social risk factors, for example, whether the person has legal problems or is unemployed; and psychiatric history, such as a mental health disorder. Physicians “can watch for abhorrent behaviors for those who have increased risk,” Dr. Webster said.
• In managing long-term pain, physicians should not start someone on extended-release or long-term opioids.
• Physicians should look for co-morbidities, including bipolar disorder, general anxiety disorders and other mental health disorders.
• Assess patients for apnea, because methadone and other medications can increase the risk for sleep-disordered breathing.
• When initiating and titrating methadone, never start a patient at a total daily dose higher than 15 mg, and dose escalation should not occur more than every seven days. The problem, Dr. Webster said, is that methadone has a variable half-life ranging from 12 to 100 hours.
• Avoid prescribing benzodiazepines with opioids. Among other problems, it increases opioid toxicity and adds to the sleep apnea risk.
• Exercise caution. Assume that every patient is opioid naïve when prescribing a new medication. Also, don’t use conversion tables when starting a dose or increasing a dose, because those tables are based on a patient being on the opioid for 24 hours in a postop situation, not long term.

The AMA will continue to host seminars in the coming months to help physicians learn about appropriate pain management. The webinar is available free online (link).