Module 4: Reducing the Risks of Opioids


Reducing the Risks of Opioids

Applying CDC's Guideline for Prescribing Opioids

Slide narration: Hello, and welcome to the fourth module of the CDC series: Applying CDC's Guideline for Prescribing Opioids. In this module, we'll look at the CDC-recommended options for reducing the risks of opioids. You will have the opportunity to learn more about strategies to mitigate risk for your patients taking opioids. You will also learn about how to use results from urine drug testing (UDT), prescription drug monitoring program (PDMP) checks, and medical history and physical examinations. At the end of the module and throughout, you will be presented multiple choice knowledge checks to test your mastery of the content.

CDC Guideline for Prescribing Opioids for Chronic Pain

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CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016

Narration text: You may find it useful to refer to the CDC Guideline during this module. You can access, download, and print a copy of this and other helpful documents by selecting the Resources tab at any time. Some screens include a link icon which, when selected, opens additional online resources. Let's take a closer look at the navigation features of this web-based training. As you've experienced already, the Next and Back buttons enable you to move to a new screen or back to a previous screen. If either the Next or Back button is dimmed, it is disabled, and you will need to complete an action onscreen to continue. Refer to the navigation prompt located at the bottom of the screen to help you determine how to proceed. Selecting the Menu button in the upper right corner opens a list of all the topics available in the module. A selection made from the list advances the training to that topic. Pressing the open Menu tab a second time will collapse it. There is also a set of audio controls located at the bottom of the training window. Here you can pause or play the narration, control the volume, and open the text transcript for the narration if needed. Most slides, however, will not be narrated, and this set of controls will be dimmed and disabled.

Module Objectives

After completing this module, you should be able to:

Facts about Opioid Overdose

Improving the way opioids are prescribed will ensure patients have access to safer, more effective chronic pain treatment while reducing opioid misuse, abuse, and overdose.

Ensuring Safety of Patients Taking Opioids

Prescription drug monitoring programs (PDMPs), urine drug testing (UDT), and patient education are important components of ensuring patient safety.

Prescription Drug Monitoring Program (PDMP)

PDMPs are state-run databases that track prescriptions for controlled substances. Providers can review a patient's history of controlled substance prescriptions and determine whether the patient is receiving opioid dosages or dangerous medication combinations that put him/her at high risk of overdose. It is a valuable tool for safer opioid prescribing. State requirements vary, but CDC recommends checking the PDMP prior to every opioid prescription and at least once every three months when prescribing opioids for chronic pain.

There are some limitations to PDMP data. Providers treating patients who obtain prescriptions in multiple states may not have the ability to view the complete picture of prescription data without access to multiple state PDMPs. Medications prescribed in opioid treatment programs and in a closed program, such as Veterans Health Administration facilities, may not be listed in a state's PDMP.

Urine Drug Testing (UDT)

UDT can provide information about drug use that is not reported by the patient. UDT results provide data regarding whether a drug is in the urine at a threshold concentration but doesn't necessarily provide data regarding whether someone is taking the opioid as prescribed.

There is a differential diagnosis for all UDT findings (expected or unexpected). Also, UDT can be tricky to interpret and might require consultation with the laboratory or local toxicologist for proper interpretation. In addition, there is the potential for false-positive or false-negative results. Lastly, not every drug of interest is included in all UDT panels.

Patient Education

Before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy, and patient and provider responsibilities for managing therapy.

Checking the PDMP to Improve Patient Safety

PDMPs can help to improve patient safety in multiple ways.

Identifies More Than One Prescriber

It allows providers to identify patients who are obtaining opioids from more than one provider and thus might be receiving high total daily dosages of opioids.

By checking your state's PDMP, you are taking an important step in the safer prescribing of opioids. States that require PDMP checks prior to prescribing show reductions in the number of patients with multiple prescribers1, 2

Identifies Dangerous Medication Combinations

It identifies patients who are being prescribed other substances, such as benzodiazepines, that may increase risks associated with opioids. Please note that non-controlled substances do not appear in the PDMP, nor do medications prescribed in an opioid treatment program.

Provides Timely, Updated Data

State requirements vary, but CDC recommends that providers review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months.

Finding Concerning Information in the PDMP

If you find concerning information in the PDMP, do not dismiss patients from care. You should share and discuss the findings with other providers.

You should confirm the patient is aware of additional prescriptions. Also, you should discuss safety concerns with the patient, such as increased risk for respiratory depression and overdose. You can use the opportunity to provide potentially lifesaving information and interventions.

You should calculate the total morphine milligram equivalent (MME) per day to help assess the patient's overdose risk. If it is high (≥50 MME/day and especially ≥90 MME/day), consider tapering to a safer dosage, offering naloxone, and assessing for opioid use disorder.

Mitigating Opioid Risk Scenario 1

Note: All names and addresses used in this module are entirely fictional, and any resemblance is purely coincidental.

Patient Chart for Smith, Ann

DOB: 4/11/1955

New patient to your practice, transferring care due to insurance change

Medical history: Bilateral knee osteoarthritis diagnosed 15 years ago; Has been taking 3-4 hydrocodone/acetaminophen 10/325 mg tablets each day for the past 10 years for pain management; Rides her bicycle 2-3 times per week

No documentation of UDT is found.

PDMP Report for Smith, Ann

Mitigating Opioid Risk Scenario 1 - Knowledge Check

Which of the following factors related to Ms. Smith's opioid therapy are particularly risky? Select all that apply.

  1. Multiple opioid prescriptions from different providers
  2. Her diagnosis of osteoarthritis
  3. History of no prior UDT
  4. The recent change in health insurance

Mitigating Opioid Risk Scenario 1 - Knowledge Check Feedback

The correct answers are A and C. Ms. Smith's PDMP data indicates she has prescriptions for opioids from multiple providers. Also, her medical records indicate that no urine drug testing has ever been performed despite her long-term opioid use.

Mitigating Opioid Risk Scenario 2

Note: All names and addresses used in this module are entirely fictional, and any resemblance is purely coincidental.

Patient Chart for Miller, Joe

DOB: 6/7/1980

Medical History: Low back pain; Onset 8 years ago following a motor vehicle crash; Takes extended-release morphine 45mg twice daily; Has tried physical therapy and regular exercise to help manage pain

Medications: Denies medications other than the opioids described above

PDMP Report for Miller, Joe

Mitigating Opioid Risk Scenario 2 - Knowledge Check

Which of the following factors related to Mr. Miller's opioid therapy are particularly risky? Select all that apply.

  1. Multiple opioid prescriptions from multiple providers
  2. Patient denial of other opioid prescriptions
  3. High daily opioid dosage
  4. His concurrent use of nonopioid therapies
  5. Lack of documented UDT

Mitigating Opioid Risk Scenario 2 - Knowledge Check Feedback

The correct response is A, B, C, and E. Mr. Miller is receiving multiple opioid prescriptions from multiple different providers, and he did not disclose this information. Also, he is taking an unsafe high daily dosage of opioids, not even factoring in the extra prescriptions he received from his dentist and from another physician. We now know that high dosages of opioids increase the risk of overdose and development of opioid use disorder. Lastly, there is no documentation of a urine drug test despite long-term opioid use.

Incorporating nonopioid treatment modalities - including both nonopioid pharmacologic options and nonpharmacologic options like exercise - is actually an important first-line strategy to treat pain.

Populations at Greater Risk of Harm

Patients with the following conditions are at greater risk of harm from opioids and increased risk of opioid overdose.

Sleep Apnea or Other Causes of Sleep-Disordered Breathing

There is no clear clinical consensus regarding the association of opioids and the risk for developing obstructive sleep apnea syndrome. However, opioid therapy can: