Hero

Videos

Slideshows

Articles

Podcasts

Poll

In the midst of a nationwide opioid epidemic, there is a population that is largely being ignored. According to a large cohort study, only a small percentage of teens receive proper aftercare following near-fatal overdoses. 

 examined data from more than 4 million Medicaid enrollees (N = 4,039,216) and found that only 1 in 54 youths aged 13 to 22 years received evidence-based pharmacotherapy after an overdose. Unfortunately, it appears that proper care in this patient population is given in very few cases (

 invited lead author Rachel H. Alinsky, MD, MPH, to share insights from the study. Alinsky is an adolescent medicine and addiction medicine fellow at 

Johns Hopkins University School of Medicine

: Your research highlights the need for quality treatment, especially for younger patients. What insights can you provide about interventions and obstacles to treatment?

We need to find effective interventions that can link adolescents and young adults directly into treatment after an opioid overdose. We also need to evaluate the barriers to accessing care at the time of overdose (such as insurance restrictions, lack of community providers or treatment centers, and stigma), and find strategies to mitigate these barriers. System-level changes are necessary, such as targeting federal funding for research and treatment for youth, decreasing insurance barriers, and increasing the availability of youth-serving physicians and addiction treatment centers.

 In the study, you and your colleagues noted, “Nonfatal opioid overdose may be a critical touch point when youths who have never received a diagnosis of opioid use disorder can be engaged in treatment.” Is that because these youths have hit rock bottom?

In the addiction treatment field, we do not abide by that old adage—that people have to hit rock bottom before they are ready to get treatment. That is somewhat of a myth. What we are trying to emphasize in our article is that overdose is a particularly crucial time when we can draw someone into treatment because they are presenting into the medical setting, seeing doctors, and we have this opportunity to interact with them and offer them treatment. Coming into the emergency department with an overdose may be the only time this person is sitting face-to-face with a doctor, and we want to capitalize on this opportunity to offer the best care we can to the patient.

Of course, that does not mean they did not want treatment a month ago or a week ago—they very well might have wanted treatment but did not know how to access it in our very difficult-to-navigate addiction treatment system. So when the patient is physically with us after an overdose, we have the chance to help them gain access to lifesaving treatment.

PT: What are the key takeaway points from the study?

Prior to this study, we knew that teens and young adults were about one-tenth as likely as adults to receive treatment for opioid use disorder in general.

 And while we knew that more than 4000 adolescents and young adults between the ages of 15 and 24 die from an 

 very little was known about health care use following nonfatal opioid overdose in youth. We were interested in figuring out the extent to which adolescents and young adults are receiving evidence-based treatment after a nonfatal opioid overdose.

We found that fewer than 1 in 50 adolescents and young adults who had an opioid overdose received the standard-of-care medication treatment that is recommended by the American Academy of Pediatrics.

 We also found that youths with opioid overdose have a 

; more than 8% of youths with heroin overdose experience another overdose within 3 months.

When an adolescent or young adult goes to the hospital with an emergency, you expect them to get the treatment they need. But here we see that less than 2% are getting that treatment, which would not be acceptable for any other medical condition. In pediatrics, it would be unacceptable if only 1 in 50 youths with asthma [received] the standard treatment when they came into the emergency department, or if 1 in 50 youths with diabetes [received] the standard treatment when they were hospitalized with diabetic ketoacidosis. Pediatricians would not find that treatment gap acceptable. Yet this is where we are now with the treatment for youths who have an opioid overdose—and we need to do better for them.

Additionally, with such high rates of recurrent overdose, it is even more important to get these youths into effective treatment as soon as possible, so we can try to prevent another overdose.

Finally, prescribing practices should be closely monitored in young people; they are a critically neglected patient population when it comes to addiction monitoring. As verified in an earlier study of 2,752,612 adolescents: “Safe opioid prescribing practices are critical to mitigate the risk of prescription opioid overdose in adolescents and young adults.”

PT: What are the key issues in recognizing opioid use disorder in youth?

The diagnosis of opioid use disorder is straightforward and is based on how many criteria an individual meets from a set of 11 criteria defined in DSM-5. In the case of youths who are presenting with opioid overdose, there is a chance that clinicians may view this as a standalone incident, and not recognize it as a manifestation of an adolescent’s underlying opioid use disorder. Thus, clinicians should be thinking about, and evaluating for, opioid use disorder in any youths that present with an overdose. Clinicians should probe for issues such as taking the opioid in larger amounts than intended, unsuccessful efforts to cut down use, cravings, recurrent use despite failure to fulfill obligations at school or home, or recurrent use in physically hazardous situations.

In terms of treatment, psychiatrists and other providers should offer medication for opioid use disorder as first-line treatment, consistent with recommendations from the 

. These medications include buprenorphine, methadone, and naltrexone. Pharmacological interventions can be combined with behavioral health services such as therapy or counseling. The provider will need to determine the level of care that will best support the patient in their current stage of treatment—inpatient hospitalization, residential treatment, intensive outpatient, or outpatient treatment.

We know that medication is effective and lifesaving for opioid use disorder; large studies in adults have found that medication cuts the risk of death in half.6,7 We also know that youths who are on medication stay in treatment longer.8 Because so few youths actually ever receive this effective addiction treatment, an overdose can be an ideal opportunity to link someone into care who has not been able to access it previously.

How can clinicians advise their patients and families on finding the most appropriate care?

Patients and their parents can advocate for treatment by asking their doctors about treatment when they are in the emergency department with an overdose. Some emergency departments have programs where patients can immediately start on medication treatment; the programs can then link them to a provider in the community. These programs have been shown to be extremely effective, with much higher rates of individuals entering and staying in treatment than if someone is simply handed a phone number to call to set up treatment.9 If that sort of linkage is not available, families should ask to be referred so their teen or young adult can receive treatment in their community as soon as possible.

Clinicians or patients and families who want to find available treatment resources within their community can use the treatment locator provided by the Substance Abuse and Mental Health Services Administration (

). Here you can enter your zip code and find all the available addiction treatment centers, sorting by services offered. It is also possible to specifically look for buprenorphine prescribers or methadone programs from that web page.

1. Alinsky RH, Zima BT, Rodean J, et al. 

Receipt of addiction treatment after opioid overdose among Medicaid-enrolled adolescents and young adults

2. Chua KP, Brummett CM, Conti RM, Bohnert A. 

Association of opioid prescribing patterns with prescription opioid overdose in adolescents and young adults

3. Overdose death rates. National Institute on Drug Abuse. Updated March 10, 2020. Accessed November 30, 2020, 2020. 

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

4. Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. 

5. Feder KA, Krawczyk N, Saloner B. Medication-assisted treatment for adolescents in specialty treatment for opioid use disorder.

6. Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. 

7. Medications for Opioid Use Disorder Save Lives. The National Academies Press. Accessed November 30, 2020. 

http://www.nationalacademies.org/hmd/Reports/2019/medications-for-opioid-use-disorder-save-lives.aspx

8. Hadland SE, Bagley SM, Rodean J, et al. Receipt of timely addiction treatment and association of early medication treatment with retention in care among youths with opioid use disorder. 

9. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. 

With opioid use disorder, a tiny fraction of young patients are getting treatment, which would not be acceptable for any other medical condition. 

Improving Care in Teens With Opioid Use Disorder

 and Senior Vice President at Appriss Health. She is a physician and healthcare services researcher, trained in Critical Care and Emergency Medicine, and faculty at Johns Hopkins University School of Medicine.

The reported increase in opioid related overdoses, likely fed by the disturbances of COVID-19, necessitates a need for more widely-accessible Naloxone, an emergency life-saving treatment. 

Naloxone and Combatting the Rising Opioid Fatalities 

Although these medication-assisted treatments have been approved by the FDA and have strong empiric evidence for superior outcomes, it is important to know the good and the bad.

Pros and Cons of Medication-Assisted Treatment for Opioid Use Disorder

A. A 78-year-old in hospice care for terminal lung cancer

B. A 68-year-old w history of depression, anxiety, chronic pain, +drug screen for cocaine/opioids/prescribed benzodiazapines

C. A 65-year-old with hepatocellular carcinoma, recently enrolled in palliative care, w a comorbid, severe alcohol-use disorder

D. A 90-year-old who has chronic back pain, neurocognitive disorder and history of falls

E. A 64-year-old status/post hip replacement surgery in PACU

The short vignettes in this quiz highlight the importance of understanding the delicate balance between risks and benefits when prescribing opioids.

Mini Quiz: Prescribing Opioids to the Elderly

is Resident Physician, Department of Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, NY;

is Addiction Psychiatry Fellow, Dartmouth-Hitchcock Medical Center, Lebanon, NH; and 

is Clinical Associate Professor, Department of Psychiatry and Behavioral Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, and Medical Director, Consultation-Liaison Psychiatry, Cape Cod Healthcare, Hyannis, MA.

Opioid-related overdoses are now the leading cause of death in Americans aged younger than 50 years, with a resultant 2.5 months of life expectancy lost.

 While this includes deaths from pain pills and illicit heroin, the overwhelming initial source of addiction is prescribed opioids; 83% of heroin users started off abusing prescription opioids. More than 6 out of 10 deaths involve prescribed opioids.

 in the number of prescriptions written as well as dosages per prescription.

 yearly to supply every American with an average of 36 pills. In addition, in 2016, overprescribing of postsurgical opioids resulted in 3.3 billion unused pills flooding into communities, making these available for diversion and misuse.

Use of naloxone, an opioid receptor antagonist, has been shown to reverse opioid-induced respiratory suppression. Current evidence suggests that bystanders can and will use naloxone to reverse opioid overdoses when appropriately trained. This training is possible through community-based opioid overdose prevention programs. There is a movement to increase public awareness and training on the use of naloxone, with laws being passed that require students as young as elementary school age to receive training.

Despite this, there has been only a modest increase in naloxone prescribing between 2009 and 2015, from 2.8 million to 3.2 million.

 The relatively slow adoption of naloxone is in part due to stigmatization and absence of familiarity with the treatment among clinicians and opioid users. Most physicians do not receive formal training on the use of naloxone and its various methods of delivery. There is a need to increase prescribing and to improve clinicians’ training to effectively help ameliorate overdose response and deaths (

Because of the effects of the overdose epidemic, states passed legislation designed to enhance layman access to naloxone and give legal immunity to medical professionals who prescribe or dispense naloxone as well as to those who administer naloxone. Individuals such as emergency medical services personnel, police officers, and firefighters as well as those authorized to administer naloxone are required to undergo training and education in recognition of signs and symptoms of overdose, techniques for administration of naloxone, and referral to emergency medical services. Residents and fellows are the exception. They undergo training in clinical skills such as advanced cardiac life support, pediatric advanced life support, and basic life support; however, they do not receive naloxone and opioid reversal training. Training is relatively simple in part because of the absence of complicated administration requirements or serious adverse reactions (

Naloxone competitively antagonizes the delta (Î´), mu (Î¼), and kappa(Îº) receptors with a 10-fold higher affinity for Î¼ than Îº. Given its ability to displace receptor-bound opioid molecules, its main use is intended for reversal of opioid-induced respiratory 

 Evidence of efficacy is noted within 30 seconds of intravenous administration; however, the most common route is nasally with a spray. This allows for convenient administration to patients by their relatives at home. The recommendation is to create an “overdose plan” to share with friends, partners, and/or caregivers. Such a plan contains information on the signs of overdose and how to administer naloxone or otherwise provide emergency care.

A medical provider must have a high suspicion and low threshold for use of naloxone, since overdose patients are usually found unresponsive or sedated. This is particularly true in cases where getting a collaborative history from a relative or close companion is difficult.

Currently, there are 4 naloxone delivery systems (

The onset of action of naltrexone and the duration depend on the route of administration. When used intravenously, it has the quickest onset of action (1-2 min) compared with subcutaneously (5 min), intramuscular (6 min), and nebulized (5 min).

 recommend initial doses of 0.4 to 2 mg via intramuscular or intravenous routes, followed by repeated doses up to 10 mg.

 Dosing is empirically determined; however, many factors need to be considered including morphine equivalence in the system, naloxone administration route, concurrent medications in the system such as benzodiazepines, and overall opioid tolerance.

Typical administration begins with a low dose to avoid precipitating withdrawal. Considerably higher doses of naloxone are required for potent opioids such as fentanyl.

 This should be a consideration in an individual who does not respond to the initial dose. Because of the increased prevalence of fentanyl and other powerful synthetic opioids, the naloxone requirements are on the rise. Given the potency of fentanyl, even multiple doses are sometimes unsuccessful.

Naloxone’s safety profile is extremely high especially when used in low doses and titrated to effect. When administered to nonopioid-dependent and nonopioid-intoxicated healthy volunteers, it produces no clinical effects even at high doses. Even in tolerant patients, rapid opioid withdrawal-although unpleasant-is not always life-threatening.

The duration of action of some opioids exceeds that of naloxone and can result in recurrence of CNS and respiratory system depression. It is important to be prepared for additional administrations and to be able to facilitate ICU admission for monitoring after reversal. It is also pertinent to consider the limitation of naloxone when dealing with mixed agonists/antagonists and partial agonists because of the low efficacy of the drug.

When used in cases of opioid overdoses, the abrupt reversal can sometimes result in vomiting, sweating, increased blood pressure, tremulousness, and tachycardia. Naloxone can also cause acute withdrawal symptoms in opioid-dependent individuals. Agitation, yawning, diaphoresis, rhinorrhea, lacrimation, nausea, vomiting, and diarrhea are not life-threatening.

 At the same time, in rare cases, it is possible to encounter 

 such as pulmonary edema, acute respiratory distress syndrome, seizures, and cardiac arrhythmias.

 Because of the short half-life of naloxone, withdrawal symptoms have a tendency to dissipate in approximately 30 minutes to 1 hour. In the case of an overdose, the risk of the symptoms listed above are balanced against the risk of death. (It is important to note that most overdoses typically involve co-administrations of benzodiazepines and opioids; hence, it is important to consider and be able to manage both.)

There has been criticism from some emergency department physicians who view naloxone prescription as perpetuating drug abuse. Some argue that users are not afraid to indulge in drug use because they know that there is a potent antidote. As users indulge more and more in this practice, they develop tolerance to the effects of the opioid drugs. An increased tolerance results in a continuous and upsurge use of 

 and leads to emergency department presentations.

 Emergency department physicians frequently face serious ethical dilemmas of either medically helping patients recover or playing a part in propagating their drug use.

An increasing number of individuals refuse naloxone treatment because they fear that it will precipitate withdrawal symptoms. This can be prevented through appropriate dosing, and patients can be reassured on arrival to the hospital that if withdrawal symptoms are noted, supportive treatment will be initiated. Some patients who experience these unpleasant symptoms will ask for early discharge with the hope of going back to using opioids to control their symptoms. Thus, there is a need for close collaboration between all the stakeholders concerned with the care of these patients.

Instead of discharge, best outcomes are achieved when patients are referred to drug rehabilitation centers for further management and law enforcement authorities notified to ensure that the patient is compliant with rehabilitation.

 This is even more effective when medication-assisted therapy with buprenorphine-naloxone is initiated before hospital discharge.

Individuals who have DNR statuses and are found comatose should still receive naloxone resuscitation as part of correct medical ethics conduct. If upon reversal, when they awaken, they continue to maintain a DNR stance, subsequent dosing should still be administered if needed, provided it is part of the overdose sequela while collaborating with the institution’s medical ethics council.

There is reassurance that prescribing naloxone to manage opioid overdose is consistent with the drug’s FDA indication, which results in no increased liability as long as the prescriber adheres to general rules of professional conduct. State laws and regulations generally 

 from prescribing to a third party, such as a caregiver. Illinois, Massachusetts, New York, and Washington State are the exceptions to this general principle.

The authors report no conflicts of interest concerning the subject matter of this article.

 Dowell D, Arias E, Kochanek K, et al. Contribution of opioid-involved poisoning to the change in life expectancy in the United States, 2000-2015. 

 Centers for Disease Control and Prevention. Wide-ranging online data for epidemiologic research (WONDER). 2016. https://www.healthdata.gov/dataset/wide-ranging-online-data-epidemiologic-research-wonder. Accessed November 16, 2017.

 New Research: Overprescribing of Postsurgical Opioids Poses a Serious Threat to Patients and Their Communities. 2017. https://finance.yahoo.com/news/research-overprescribing-postsurgical-opioids-poses-120000057.html?.tsrc=rss. Accessed November 16, 2017.

 Gupta R, Shah ND, Ross JS. The rising price of naloxone: risks to efforts to stem overdose deaths. 

 Walley AY, Sorensen-Alawad A, Dwyer K, et al. Nasal naloxone rescue kits in an emergency department overdose education program. 

 Kim HK, Nelson LS. Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. 

 FDA Advisory Committee on the Most Appropriate Dose or Doses of Naloxone to Reverse the Effects of Life-threatening Opioid Overdose in the Community Settings. 2016. https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/AnestheticAndAnalgesicDrugProductsAdvisoryCommittee/UCM522688.pdf. Accessed November 16, 2017.

 Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. 

 Greene S, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a nutshell. 

 Rudd-Barnard G, Pangarkar S, Moaleji N, Glassman P. Epidemiology of naloxone use for opioid overdose in a tertiary care medical center. 

 Lin RJ, Reid MC, Chused AE, Evans AT. Quality assessment of acute inpatient pain management in an academic health center. 

 Jones JD, Roux P, Stancliff S, et al. Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users. 

 The Network for Public Health Law. Using Law to Support Pharmacy Naloxone Distribution. https://www.networkforphl.org/_asset/qdkn97/Pharmacy-Naloxone-Distributions.pdf. Accessed November 16, 2017.

 Guidelines for Opioid Overdose Education and Naloxone Distribution. 2015. http://www.ct.gov/dph/lib/dph/aids_and_chronic/prevention/pdf/open_access_ct_guidelines.pdf. Accessed November 16, 2017.

More than 6 out of 10 deaths involve prescribed opioids. The authors address guidelines for who should (and who should not) receive a naloxone prescription.

Opioid Overdoses and Naloxone: What Everyone Needs to Know

Dr. Suryadevara is Assistant Professor, Department of Psychiatry, University of Florida, Gainesville, FL, and Assistant Professor, North Florida/South Georgia VAMC, Psychiatry, Gainesville, FL. Dr. Holbert is Assistant Professor, Department of Psychiatry, University of Florida, and Dr. Averbuch is Associate Professor, Department of Psychiatry, University of Florida.

The United States is currently in the midst of an opioid epidemic. The numbers are staggering: in 2016 there were 78 deaths per day from drug overdose, two-thirds of which involved opioids. Since 1999, deaths from opioid prescriptions have more than quadrupled.

As is often the case, the origins of this epidemic are multifactorial. Some overprescribing can be traced back to the health care profession’s efforts to recognize pain as the fifth vital sign, which compelled physicians to treat more aggressively. Some pharmaceutical companies may have also contributed to the problem through aggressive marketing of prescription opioids without proper emphasis on their addictive potential. Regardless of the cause, the problem is pervasive, affecting all socioeconomic groups and spheres of society.

While opioid use disorders are more common in younger patients, prevalence among the elderly is growing, and misuse poses unique risks in the geriatric population. From 1996 through 2010, the number of opioid prescriptions provided to older patients increased 9-fold. More alarming, 35% of patients aged older than 50 years with chronic pain reported misuse of their opioid prescriptions in the past 30 days.

 The hospitalization rate for geriatric misuse of opioids has quintupled in the past 20 years alone.

 Given the scope of the problem, federal and state governments have begun to implement new guidelines in prescribing opioids, but tighter regulations may intrude on individualized patient care and the benefits of opioid therapy in some patients. Whether these new policies are the best strategies remains to be seen.

Avoidance of iatrogenic addictions may be the first step in addressing the epidemic. Some situations are more straightforward. Most clinicians can distinguish which of the following fictional cases is an inappropriate use of opioids: a 78-year-old in hospice care for terminal lung cancer; a 65-year-old who underwent major surgery that morning; or a 68-year-old with a history of depression, anxiety, and chronic pain, and a urine drug screen positive for cocaine, opioids, and benzodiazepines (prescribed). Contrast that with more complex, typical clinical scenarios in which the distinction can be a real challenge.

Mr. X is a 66-year-old under hospice care for hepatocellular carcinoma, with a comorbid severe alcohol use disorder. Opioids were prescribed until his urine drug screen came back positive for marijuana and cocaine. Two days after opioid therapy was stopped, the patient was found dead due to a self-inflicted gunshot wound. Pain was determined to be a major contributing factor. This case highlights the importance of understanding the delicate balance between risks and benefits when prescribing opioids, and the unique role psychiatrists play in their use.

Opioids reduce the perception of pain and produce a sense of well-being by binding to opioid receptors (mu, delta, and kappa) distributed in the brain, spinal cord, and other peripheral tissues. When deeper brain regions are stimulated by opioids, drowsiness and respiratory depression ensue. Opioids are classified by their origin, mechanism of action, or potency. Based on their origins in nature, opium, morphine, and codeine are opiates. Semi-synthetics include hydromorphone, hydrocodone, oxycodone, and heroin. Completely synthetic opioids are manmade and include fentanyl, methadone, pethidine, levorphanol, tramadol, and dextro­propoxyphene. Based on their potency, codeine, hydrocodone, and oxycodone are considered mild opioids; morphine, meperidine, hydromorphone, fentanyl, and methadone are classified as major opioids. All are opioid agonists with the exception of buprenorphine, which is a partial agonist/antagonist.

Opioids are generally used for acute and chronic pain, active-phase cancer treatment, palliative care, and end-of-life care. The latter situations are relatively straightforward as the benefits are uniformly perceived to outweigh the risks. Standards for treatment of acute pain are similarly uniform among most physicians, with only minor variations. For treatment of nonmalignant chronic pain, there is far less agreement among providers. There are no clear data to support the long-term effectiveness of opioids in these conditions. Hence, guidelines have been established on when to initiate or continue treatment, selection of the proper opioid, dosage, duration of use, and when to discontinue therapy. These guidelines also outline how to conduct a thorough risk assessment and address potential pitfalls.

Opioids are also used for non-medicinal, recreational purposes. In the elderly, the line between use for physical and psychological well-being is often blurred, which complicates attempts to determine prevalence. Numbers vary for different countries and are based on different study results, further confounding the data. This variation in prescribing patterns could be a result of the inconsistent practice styles among physicians and a failure to adhere to the guidelines that aim at standardizing practice. The changing demographics of the elderly American population further influence the prevalence of substance use disorders.

The decision to prescribe opioids in the elderly requires careful consideration of the many pharmacokinetic changes associated with aging. Age-related changes include a decrease in hepatic blood flow and volume along with decreases in renal blood flow and the glomerular filtration rate. Depending on the opioid used, it is essential to estimate the creatinine clearance and hepatic function for appropriate dosing adjustments. Other age-related changes that may influence opioid levels include decreased rates of absorption and increased adipose tissue. Many comorbid medical conditions seen in the elderly can lower the serum albumin concentration, thereby increasing the free opioid concentration.

Additional risks include the potential for serious drug-drug interactions with opioids. The likelihood of such interactions is directly proportional to the number of medications prescribed and compounds the risk of serious adverse events such as respiratory suppression.

Elderly patients often take a number of medications, and the combination of polypharmacy-related drug interactions, pharmacokinetic changes seen with aging, and multiple comorbidities can make pain management particularly challenging. The management of pain in the long-term care setting poses an additional set of challenges. According to the American Geriatric Society, nearly 80% of elderly patients in long-term care settings have substantial pain, yet 25% do not receive any treatment.

Patients at the highest risk for inadequate pain control include members of racial and ethnic minority groups, women, the elderly, those with cognitive impairment, and those with terminal cancer. Persistent and undertreated chronic pain can lead to a variety of negative psychosocial and clinical consequences, including limitations in daily functioning, disruption in workplace productivity, stress in interpersonal relationships, and worsening medical conditions.

Non-opioid pharmacotherapy and non-pharmacological therapy are the preferred modalities of treatment for chronic pain. However, in the proper contexts, opioids can be a useful treatment option. They are most beneficial in the short term for acute injuries, including the management of pain postoperatively. Use should be time-limited, except in managing certain cancer-related pain syndromes and as a part of end-of-life care. Particularly in the elderly, appropriate precautions must be taken.

Obtaining a thorough history is the first step. Screen for a history of opioid use disorder or other addictive disorders, including nicotine use disorder and any family history of addiction. A complete psychosocial history, including current stressors, history of childhood abuse or neglect, legal problems, and interpersonal relationship stressors will help to identify high-risk opioid misusers. Comorbid depression and high levels of pain are additional risk factors for misuse of opioids in the elderly. Always screen for cognitive deficits and other psychiatric disorders. Depression and anxiety may increase the perception of pain and require a different approach to pain management altogether.

Be alert for certain findings on the mental status exam such as confusion or any other indicators of a clouded sensorium, disheveled or unkempt appearance, thought content preoccupied with opioids, and dramatic or exaggerated pain-related behaviors suggestive of drug-seeking. While doing a chart review or using prescription monitoring programs, look for doctor shopping and requests for early refills. Other red flags include patients’ keeping only the appointments related to pain management, a history of positive urine drug screens or refusal of such monitoring, losing pain prescriptions, and having multiple providers prescribing the same or similar classes of medications.

After a complete history and examination, if the decision is made to begin opioid therapy, a detailed list of all medical conditions, allergies, and medications-including over-the-counter and herbal remedies-must be obtained and regularly updated. Drug selection should be based on careful consideration of potency needs and individual patient characteristics. Before initiating therapy, realistic treatment goals should be set after careful consideration of pertinent risks and benefits.

Begin with low doses and gradual titration, monitoring regularly for adverse effects and drug-drug interactions (Table). Common adverse effects include constipation, dry mouth, tolerance, dependence, nausea, vomiting, drowsiness, confusion, and low blood pressure. Warn patients about the risk of withdrawal with abrupt discontinuation. Serious adverse effects include respiratory depression leading to death, especially when mixed with benzodiazepines or alcohol. The use of benzodiazepines is contraindicated in patients who are receiving opioid therapy.

Combining analgesics with different mechanisms, together with nonpharmaceutical pain management strategies, may improve outcomes and minimize the need for opioid dose escalations. With multiple states enacting laws to legalize marijuana for medical conditions, marijuana may be one remedy for the opioid crisis. Some studies have shown that the hospitalization rates related to opioid abuse and overdose have decreased significantly in the states that offer medical marijuana. However, we should caution that the evidence is still preliminary and in need of further review. Moreover, the availability of multiple preparations and potencies makes uniform recommendations a particular challenge.

When opioids are deemed appropriate for the treatment of pain, monitor use carefully and be vigilant for patient misuse. State-sponsored, prescription drug monitoring programs may be an invaluable tool. Should signs of misuse, abuse, or diversion emerge, clinicians are encouraged to avoid outright dismissals from treatment, opting instead for referrals or in-patient treatment of substance use disorders. Patients should be given the opportunity to choose either medication-assisted treatment with buprenorphine or methadone maintenance or naltrexone. These treatments are often coupled with behavioral therapies to help with addiction.

Patients who are taking opiates should also continue to be monitored for drug-drug interactions, particularly with anti-epileptics, antidepressants, and other drugs metabolized primarily by the cytochrome P-450 system. Opiates are also notorious precipitating factors for delirium, but there is no clear evidence that the risk varies based on the type of opiate used.

 If an opioid regimen proves ineffective, clinicians may rotate the opioids or change the formulation based on consideration of pharmacokinetics and metabolism. Urine drug screens are routinely employed to check for the presence of other illicit or contraindicated substances and to investigate suspicions of drug diversion.

There is no evidence to support the long-term use of opioids for the treatment of chronic pain in the elderly. Rather, there is extensive literature that shows possible harm from long-term opioid use. For acute pain management, 3 days of opioid treatment is sufficient. In rare cases, this may be extended to 7 days. Immediate-release formulations are preferred over long-acting preparations. In cases of longer-term opioid therapy, clear and measurable treatment goals should be established and monitored regularly.

Assessments should focus on overall functioning and activities of daily living. Progress should be reevaluated no less frequently than every 3 months, with appropriate consideration for the taper or discontinuation of therapy, particularly in the absence of clinically meaningful improvement. We cannot overemphasize that, particularly in the elderly, opioids are far more effective when accompanied by a comprehensive and multidisciplinary approach using psychological support, physical therapy, and other complementary therapies.

There are legitimate uses for opioids in the treatment of a variety of pain conditions. However, the significant risks associated with opioid prescription must be carefully weighed against the potential benefits. The alarming rise in fatalities seen with the current opioid epidemic provides a vivid illustration of this challenge.

Our “textbook” and real-world cases illustrate the application of prescribing recommendations. Based on these principles, most clinicians would feel justified prescribing opioids for the cases of the 78-year-old in hospice care for terminal lung cancer as well as the 66-year-old in hospice care for hepatocellular carcinoma. However, in the latter case, the patient’s comorbid substance use disorder as well as the evidence of misuse on drug screening provides a more complex, real-world scenario. Such cases require difficult clinical decisions-sometimes with untoward outcomes. It is our hope that understanding the guidelines, following the standards of care, and documenting the same will help clinicians provide better care to complex elderly patients.

 Prevention, CDC Injury. (2016). Control: Prescription Drug Overdose. August 2017. 

https://www.cdc.gov/drugoverdose/epidemic/index.html

 West NA, Severtson SG, Green JL, Dart RC. Trends in abuse and misuse of prescription opioids among older adults. 

 Chang YP, Compton P. Opioid misuse/abuse and quality persistent pain management in older adults. 

 Owens PL, Barrett ML, Weiss AJ, et al. Hospital Inpatient Utilization Related to Opioid Overuse Among Adults, 1993-2012. August 2014. 

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb177-Hospitalizations-for-Opioid-Overuse.jsp

 Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. 

 RodrÃ­guez MJ, de la Torre R, Ortega JL, et al. Evaluation of the quality of care of elderly patients with chronic and breakthrough pain treated with opioids: SAND study. 

 Guy GP Jr, Zhang K, Bohm MK, et al. Vital signs: changes in opioid prescribing in the United States, 2006-2015. 

Jones J, Sim TF, Hughes J. Pain assessment of elderly patients with cognitive impairment in the emergency department: implications for pain management: a narrative review of current practices. 

 Dubois MJ, Bergeron N, Dumont M, et al. Delirium in an intensive care unit: a study of risk factors. 

 Swart LM, van der Zanden V, Spies PE, et al. The comparative risk of delirium with different opioids: a systematic review. 

While opioid use disorders are more common in younger patients, prevalence among the elderly is growing.

Opioid Use in the Elderly

You were too young. You were supposed to get better. You weren’t supposed to die.

I am 3 months into my intern year and well into a daily routine. Wake up near dawn, put on my weekday best, go to the hospital, and then come home to finish notes and kiss my wife goodnight. But today after lunch, I get a text message and the routine is shattered.

“Did you hear your patient died? He jumped off a bridge last night . . . I’m watching the local news. They identified his body.”

His name was “Ryan,” and he was only 28. He was on the dual diagnosis unit for a week before being discharged. The team had assessed that he wasn’t actively suicidal. Yet two days later, he’s dead.

I am in a state of disbelief and my head is spinning. Was he high or was it deliberate? Could I have done more or did I do too much? What should I have said that I didn’t, or shouldn’t have said that I did? Was it poor judgment to discharge him? I had direct responsibility for trying to help him get better.

Two weeks earlier, Ryan was standing on the side of a bridge when the paramedics found him. He was high on heroin and suicidal, and consequently, he was hospitalized again (this was the third time in a month). His life had completely fallen apart. His family relationships were damaged: he had no intimate partner, support group, or cohesive identity. He was poorly educated and unemployed. He was kicked out of multiple homes and had legal charges pending. He was without a safety net.

After detox, we spent hours together discussing treatment options and I was attempting to help him discover the motivation to stop using heroin. When he was sober, Ryan was introspective, respectful, and soft-spoken. Though he initially seemed encouraged, his interest quickly faded with each passing day without heroin. When asked what his goals were, Ryan said he wanted to leave and start using again.

Psychiatric illnesses are often seen as deficiencies in behavior, character, or personality and qualitatively different from advanced cancer, diabetes, and pneumonia.

Each day, I felt like I was falling short when trying to reach him-I was completely powerless against his opiate addiction. Though I spent considerable effort trying to engage Ryan, he remained aloof and disinterested. I wanted to alleviate his suffering with alternatives to opiates. He was convinced that medicines and psychotherapies were ineffective. His addiction had damaged his life severely. He recognized heroin was dangerous but said it was worth the trouble. Even so, after multiple discussions, Ryan expressed a willingness to follow up with an outpatient program and case manager. I had hoped he was genuinely committed to taking steps toward building a meaningful life and he wasn’t appeasing me to secure his discharge. I suppose the hoping didn’t matter in the end.

I still can’t believe it. I was worried what might happen if you started using again. You said it yourself, that maybe next time you were high you would jump off a bridge. But I wasn’t expecting you to die so soon. I didn’t expect to feel such intense grief, with powerful guilt and shame, even though I knew I gave you my all. But I couldn’t, and wouldn’t, have kept you locked up in the hospital against your will unless absolutely necessary. Even my best effort wasn’t enough to keep you alive.

But maybe keeping Ryan alive wasn’t a realistic goal at all. We routinely discharge terminally ill patients from medical units to hospice care with the expectation that they will die from their terminal medical illness within 6 months. Why should we feel more responsibility for discharging people with terminal psychiatric illness? A dichotomy between “psychiatric” and “medical” illnesses pervades our culture. Psychiatric illnesses are seen as deficiencies in behavior, character, or personality that should be remedied; therefore, they can’t be terminal. Somehow, they are qualitatively different from advanced cancer, diabetes, and pneumonia-perhaps, in part, because we don’t understand psychiatric disorders as well as other specialists understand their areas of medicine.

We reject the idea that young people with advanced psychiatric illnesses should be allowed to die, yet we accept that those stricken with terminal cancer be allowed to die without being stigmatized for having brought it upon themselves. We expect suicide to be preventable but are allowed to say that cancer is untreatable once it progresses to a certain stage, since the treatment is often worse than the disease. Couldn’t we say the same about severe schizophrenia or bipolar disorder, that the treatment is sometimes worse than the illness? But often in severe mental illness, death is less predictable than in cancer and therefore unexpected when it happens.

As physicians, we accept death from a medical illness as one possible outcome. When death occurs in psychiatry, however, we often feel shocked and guilty. Even when one provides appropriate care, death is sometimes unavoidable. Imagine you are an emergency room physician treating a patient suffering from a heart attack. Her cardiac condition is treated promptly, appropriately, and effectively; she improves. You feel like you saved her life; that the dangerous part is over. However, two days later, she has a fatal arrhythmia. You begin revisiting everything you did (or didn’t do) for her.

After determining you provided appropriate care, you might accept your limitations and confidently take care of your next patient. Why should suicide be different? Heart disease is the leading cause of death in older adults. And suicide is the third leading cause of death in young adults.

Clearly, I’m not immune to this ultimate “bad” outcome. And Ryan’s untimely death doesn’t mean that I am an incompetent or worthless physician. It just highlights my limitations in treating terminal psychiatric illnesses.

Just as we cannot fully control outcomes in advanced heart disease, we also cannot do so in advanced psychiatric illness. I have and will always try to engage a patient with complete acceptance, unconditional regard, and without judgment. Sometimes that may inspire internal patient motivation to modify behavior. Other times a patient may trust in pharmacological and behavioral interventions. In Ryan’s case, I couldn’t help him find another way to manage his social anxiety and opioid use disorder.

I’m thankful for the chance to know and accept my limits. This acceptance frees me from the impossible expectations of perfection and complete control.

Ryan, I hope you’ve made peace and you’re no longer suffering. You’ve deepened my passion for treating serious mental illness and ensuring that stigma is minimized or eliminated during the process. By sharing your story, I hope my professional colleagues will take the opportunity for self-reflection and growth. I hope we all can accept our limits and muster the courage to continue improving our lives and the lives of others.

 I would like to acknowledge the wonderful support and contributions from my wife, Cecilia Huang; my clinical mentor, Antoine Douaihy, MD; my residency program directors, Mike Travis, MD and Sansea Jacobson, MD; and my entire Western Psychiatric Institute and Clinic family.

Dr. Hoftman is a Resident Physician in Psychiatry at the University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.

A psychiatrist realizes he is completely powerless against his patient's opiate addiction.

The Freedom in Accepting Our Limits

During the past several years, there has been increasing focus on opioid analgesics.

 Opioid use disorder related to prescription opioid analgesics is considered to be at epidemic proportions in the US. Moreover, it has been widely asserted that the overprescription of these drugs has resulted in the growing use of heroin.

In fact, we know relatively little about the causes of this crisis-and even less about the patients who run into problems with prescription opioids that were originally prescribed for legitimate pain complaints. The following questions seek to separate what we actually know about opioid analgesics and their use and misuse from what we don’t.

1.True or false? A significant number of patients treated with prescription opioid analgesics for pain turn to heroin when their opioid analgesics are discontinued.

 Although there are frequent reports that any limits on the prescribing of opioid analgesics to patients with pain will result in their using heroin if these drugs are discontinued, virtually no research supports this. Even among people who use prescription opioids for nonmedical reasons, only a small minority also use heroin.

2. True or false? The recent increase in heroin use in the US has resulted from increasing restrictions on the prescribing ofopioid analgesics.

 Research shows that the increasing use of heroin in the US began before the newer restrictions on the prescribing of opioid analgesics were instituted.

3. Which of the following is the best treatment for patients who received opioid analgesics for a legitimate pain complaint and who went on to have an opioid use disorder?

 Although there have been calls for increased treatment ofpatients with opioid use disorder with methadone and buprenorphine, there is little evidence that these medications or CBT are beneficial for patients for whom opioids were prescribed for legitimate pain complaints.

4. True or false? Urine drug testing (UDT) is sufficient to identify those patients who take opioids prescribed for legitimate pain complaints and who have or who are at risk for opioid use disorder.

 Although UDT is widely recommended for all patients who take prescription opioids, there is little evidence that it has value in identifying patients in whom an opioid use disorder will develop.

 At best it can identify patients whose opioids have been discontinued, but who continue to use one of these drugs or who use medications different from those prescribed by the physician.

5. What is the best way to determine whether opioid analgesics are beneficial for an individual patient with chronic pain?

A. Ask the patient if the medication is reducing the pain

B. Determine whether the medication is increasing the patient’s level of functioning

C. Ask if the medication makes the patient less depressed

D. Ask if the medication makes the patient less anxious

 Although reducing the levels of pain, depression, and anxiety in patients with chronic pain is important, measuring the impact of any treatment modality for chronic pain is best done by determining its effect on the level of functioning. If there is no improvement in functioning, the benefits of the treatment should be questioned.

 B. Determine whether the medication is increasing the patient’s level of functioning

6. Which of the following has been identified as a risk factor for the development of an opioid use disorder in patients who take opioids prescribed for legitimate pain complaints?

 All of these have been identified as risk factors for the development of opioid use disorder.

 However, even patients without any of these factors are still at risk for a substance use disorder, and it is unclear how many patients who develop the disorder have these risk factors.

7. True or false? The Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients With Pain–Revised (SOAPP-R) are useful instruments for predicting the likelihood that opioid use disorder will develop in patients with no identified risk factors who take opioid analgesics prescribed for legitimate pain complaints.

 Both ORT and SOAPP-R self-identify past and current history that indicates substance abuse, but neither has been found to have any predictive value for substance use disorder.

The overprescription of opioid analgesics has resulted in the growing use of heroin. Right? 

Opioid Related Disorders