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Opioids: Pretty Name, Dangerous Drugs
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It’s a very pretty sounding name, isn’t it?
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Its soft name has a certain onomatopoeic quality. Take this pretty medicine, and you’ll feel better. Your pain will go away.
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This medication even comes from a plant with a harmless-sounding name: the poppy. Doesn’t that sound like a nice plant? How can the pleasant little poppy hurt anyone? It’s even a pretty plant. Look at those sweet red petals. How nice.
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Unfortunately, as is true in many things, the pretty poppy and its nice-sounding derivatives, the opioids, hide a major dark side: the dangers of abuse and overdose. This is emphasized by a recent clinical practice guideline published by the Centers for Disease Control and Prevention1 with a nice summary and editorial by one of the guideline’s authors in the New England Journal of Medicine2.
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Let’s make it clear at the outset that these guidelines are for chronic pain management and not acute. Surgical and other acute pain management methods are not covered. As a podiatrist my philosophy is to keep my treatment of pain limited to acute pain only. For example, I tell surgical patients during their preoperative consultation that I will give them pain medications for a limited time of two months (three months for larger procedures).
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Despite this, it remains important for all of us to remain cognizant of the significance of this issue considering we see so many patients who take chronic pain medication.
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The CDC Opioid Prescribing Guideline made 12 primary recommendations for chronic pain, which I’ll summarize here1:
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Nonpharmacologic therapy is preferred.
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Before starting therapy establish treatment goals for pain and function.
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Educate patients on the risks of using opioid therapy.
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Immediate-release opioids are preferred over extended-release versions.
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Start with the lowest dose possible and titrate to effect slowly (start low and go slow).
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Since long-term use usually starts with acute treatment, physicians treating acute pain with opioids should use immediate-release opioids for no longer than the duration expected to resolve pain (no more than 3-7 days).
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Clinicians should re-evaluate patients started on opioids within 1-4 weeks.
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Periodically evaluate risk-factors for opioid-related harm.
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Review a patient’s history of controlled substance prescriptions checking state drug monitoring programs.
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When starting these medications for chronic pain consider urine drug testing to assess for the presence of these drugs and other illicit drugs.
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Avoid prescribing opioids and benzodiazepines concurrently whenever possible.
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Evidence-based methods should be used to treat patients with opioid-use disorder.
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A useful concept emphasized in the guidelines is morphine milligram equivalents (MME). Since morphine is the prototypical opioid we can compare others to it to determine relative strengths. The authors of the guidelines recommend carefully considering the risk/benefit relationship when prescribing >50 MME/day and should avoid increasing the dose above 90 MME/day1.
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Let’s take a hypothetical example from the conversion chart below (Table 1). Say I have a patient who has been taking Dilaudid (hydromorphone) 4 mg orally 6 times/day. The MME for this patient is (4 mg dose)(conversion factor 4)(6 times/day) = 96 MME. This result should raise a red flag to the provider that this patient is on a very high dose and is at high risk for opioid-related complications.
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Table 1. Common opioids and morphine metabolic equivalents3.
| Type of Opioid |
MME Conversion Factor |
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| Buprenorphine patch2 |
12.6 |
| Buprenorphine tab or film |
10 |
| Butorphanol |
7 |
| Codeine |
0.15 |
| Dihydrocodeine |
0.25 |
| Fentanyl buccal or SL tablets, or lozenge/troche3 |
0.13 |
| Fentanyl film or oral spray4 |
0.18 |
| Fentanyl nasal spray5 |
0.16 |
| Fentanyl patch6 |
7.2 |
| Hydrocodone |
1 |
| Hydromorphone |
4 |
| Levorphanol tartrate |
11 |
| Meperidine hydrochloride |
0.1 |
| Methadone |
3 |
| Morphine |
1 |
| Nalbuphine |
1 |
| Opium |
1 |
| Oxycodone |
1.5 |
| Oxymorphone |
3 |
| Pentazocine |
0.37 |
| Tapentadol |
0.4 |
| Tramadol |
0.1 |
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It’s interesting to note, looking at the table, how the common opioids stack up to morphine. It’s concerning that fentanyl, a highly common med, is seven times the dose of morphine with a very low dose to reach that 50 MME threshold. Similarly it’s unfortunate that hydrocodone and oxycodone, two of the most commonly used and abused opioids, are so similar in dose to morphine. It reminds us of the power of the medications we prescribe.
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I’m going to end our discussion with a few telling quotes from the New England Journal of Medicine referenced below 2:
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“ The prevalence of opioid dependence may be as high as 26% among patients in primary care receiving opioids for chronic non-cancer-related pain.”
“ The few randomized trials to evaluate opioid efficacy for longer than 6 weeks had consistently poor results.”
“ …Prescription opioids that are full mu-opioid-receptor agonists – nearly all the products on the market – are no less addictive than heroine.”
“ We know of no other medication routinely used for a nonfatal condition that kills patients so frequently.”
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