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Supplements Combating the Opioid Epidemic
Introduction to the Opioid Epidemic: The Economic Burden on the Healthcare System and Impact on Quality of Life
Nicholas E. Hagemeier, PharmD, PhD
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Current and Emerging Options to Combat the Opioid Epidemic
Courtney Kominek, PharmD, BCPS, CPE
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Current and Emerging Options to Combat the Opioid Epidemic

Courtney Kominek, PharmD, BCPS, CPE

 
Evaluating a patient’s level of risk is important. There are several risk assessment tools available to assist providers. These include the Screen and Opioid Assessment for Patients with Pain–Revised (SOAPP-R); Opioid Risk Tool (ORT); and Diagnosis, Intractability, Risk, Efficacy Tool (DIRE). Additionally, there are tools to assess opioid misuse. Examples include Pain Assessment and Documentation Tool (PADT), Current Opioid Misuse Measure (COMM), and Addiction Behaviors Checklist.55,56 The tools vary in their studied setting, format, number of items, time involved, scoring, advantages, disadvantages, and whether or not they have been validated. Although these tools are not lie detectors, they can assist with identifying those who are high risk and require increased follow-up and monitoring. At least one from each category should be used before initiating opioid therapy.55,56

Guidelines vary regarding recommendations for the use of risk assessment or opioid misuse tools. Literature reviews of the outcomes of screening tools have found inconsistent results and reliability issues.12,21 Thus, the CDC guideline makes no recommendation regarding the use of screening tools.12 However, the Interagency Guideline on Prescribing Opioid for Pain recommends using a validated tool to screen for opioid misuse including ORT, SOAPP-R, DIRE, or CAGE-AID combined with information from the patient’s medical record and their support system.57 The American Society of Interventional Pain Physicians includes substance abuse evaluation as part of a comprehensive assessment and providers may consider the use of screening tools for assistance.21

Treatment of Opioid Use Disorders

Medication-assisted treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a holistic approach to the treatment of SUDs. Research shows that a combination of medication and therapy can successfully treat these disorders, and MAT can help sustain recovery for some people struggling with addiction.58 Medications used in MAT include methadone, buprenorphine (with or without naloxone), and naltrexone. Methadone and buprenorphine relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances while naltrexone blocks the effects of opioids and decreases cravings. When used correctly, these medications allow individuals to function in society and maintain employment.58 Qualified physicians may apply for a waiver to dispense and prescribe buprenorphine following specialized training. As a result of CARA, these privileges have been expanded to nurse practitioners and physician assistants until 2021.2

Opioid treatment programs use tools such as the Addiction Severity Index (ASI), an interview-based modality, to measure addiction severity and treatment needs.59 Used as a baseline measurement of the severity of issues relating to substance abuse, the ASI is useful to help create a comprehensive treatment plan that addresses 6 primary categories:
  • Medical issues relating to drug use
  • Employment/support status
  • Levels of alcohol and drug use
  • Legal issues arising from substance abuse
  • Family/social factors
  • Psychiatric/mental health status
The ASI is one tool for developing an individualized treatment plan that includes ending substance abuse, finding work, improving overall mental and physical health, and addressing relationship issues. Recent studies have investigated the validity of the tool to predict the need for enhanced intervention. Simoneau and Brochu compared ASI profiles of those who re-enter treatment with profiles of individuals entering treatment for the first time.60 They found that individuals re-entering treatment had higher composite scores, which indicated a need for more intensive treatment. The use of ASI composite scores as a predictor of suicide and psychiatric care after residential treatment for drug use was recently assessed, and it was found to be useful in identifying patients with drug use disorders who could benefit from additional mental health treatment.61 Comorbid mental health problems are thought to increase the already high risk of suicide among individuals with SUDs. Identifying patients with drug use disorders who are also at high risk of suicide is an important public health task, and using data that are available as part of the routine intake assessment may lead to faster and more effective interventions that improve patients’ quality of life and reduce risk of early death and disability.61 

Opioid Treatment Alternatives

Chronic pain affects more than 100 million Americans, according to the Institute of Medicine.62 Treatment needs to be individualized and there may be several alternatives to opioids, some of which are not covered by insurance reimbursement. Oral and topical therapies may include nonsteroidal anti-inflammatory drugs, acetaminophen, antidepressants, anticonvulsants, muscle relaxants, and lidocaine patches. Nonpharmacologic options include exercise, acupuncture, and transcutaneous electro-nerve stimulator units. Interventional techniques involving injections into or around various levels of the spinal cord may include epidural steroid injections and nerve blocks.  

As a result, renewed interest in opioids that act on receptors other than µ-opioid receptors, nonopioid medications, and early intervention strategies to prevent chronic pain have emerged.63,64 Novel nonopioid therapies are in various stages of clinical development, and adjunct cannabinoid therapies have the potential to produce opioid-sparing synergistic analgesia.65 States with medical marijuana dispensaries have reported fewer opioid overdose deaths than states without them.66 However, in a national survey, cannabis use in adults with pain was associated with subsequent increases in nonmedical prescription opioid use and OUDs.67

Evidence for the efficacy of nonpharmacologic interventions for chronic pain management, such as cognitive behavioral therapy and mindfulness meditation practice, has also grown over the last several years. Mindfulness meditation has been shown to reduce the intensity of pain as well as the perception of pain control through neural mechanisms that are distinct from those of placebo effects.68,69 Unfortunately, these interventions are difficult to access in areas in which OUDs have a high prevalence, and they are less likely to be covered by health insurance, creating socioeconomic disparities in pain management.70,71

Conclusions

Numerous factors contribute to the current opioid epidemic, and although some attempts have failed, other efforts to mitigate the crisis in the United States have been effective. Risk mitigation for all patients prior to prescribing opioids is recommended and includes the use of screening tools, treatment agreements, and regular urine monitoring. Unfortunately, risk mitigation strategies have not reduced overall rates of opioid misuse or overdose. According to Schatman and Webster, although most efforts are well intended and may have prevented overdose deaths and diversion, evidence exists that the production of ADFs may work to reduce real-world abuse.72 Insurance coverage for therapies that reduce the harm associated with opioid prescribing may have the potential to substantially ameliorate the nation’s persisting prescription opioid crisis.72

Author affiliation: Harry S. Truman Memorial Veterans’ Hospital, Columbia, Missouri.
Funding source: This activity is supported by an educational grant from Daiichi Sankyo, Inc.
Author disclosure: Dr Kominek reports receiving fees for serving as a consultant for Axial Healthcare and receiving honoraria from PAINWeekEnd.
This work is the sole opinion of the author and does not reflect the opinion of employers, employee affiliates, and/or pharmaceutical companies mentioned or specific drugs discussed. It was not prepared as part of official government duties.
Authorship information: Analysis and interpretation of data; concept and design; critical revision of the manuscript for important intellectual content; drafting of the manuscript; supervision.
Address correspondence to: courtneykominek@gmail.com.
 
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