Safely Prescribing Opioids in an Era of Overdose

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Risk stratification, drug screening, and pharmacogenetic testing should guide prescribing habits.
Risk stratification, drug screening, and pharmacogenetic testing should guide prescribing habits.

The number of opioid prescriptions filled in US pharmacies has tripled since the early 1990s, skyrocketing from 76 million in 1991 to 219 million in 2001.1 During this time period, emergency department visits from opioid misuse or abuse and opioid-related drug overdose deaths also rose sharply.

Continuing the upward trajectory, emergency department visits attributable to opioids increased from 600,000 to more than 1.2 million from 2004 to 2010, and overdose deaths have quadrupled from 4000 to more than 12,000 annually from 1999 to 2010, according to data from the Substance Abuse and Mental Health Services Administration.2

“As a result many states are enacting legislation to ensure appropriate, safe opioid prescribing,” said Brett Badgley Snodgrass, MSN, APRN, FNP-C, of Comprehensive Primary Care in Bartlett, Tennessee.

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“Safe prescribing is of utmost importance, primarily to decrease diversion and abuse, but also to make it as safe and appropriate for our patients,” she said.

To ensure safe and effective chronic pain management, urine drug testing, risk stratification, and pharmacogenetic testing are also paramount.

Drug screening

“Drug screening is one of the elements we use in guiding our prescriptive habits when we're talking about opiates or controlled substances. It absolutely should be used in practice; how often depends on state mandates, the individual prescriber, and the patient,” Ms. Snodgrass said.

Drug testing helps providers determine if patients are taking their medications as prescribed, and also if they are taking other drugs that may interfere with their medications. A variety of screening methods are available, including urine analysis, blood immunoassays, and gas chromatography/mass spectrometry (GC/MS).

“Urine drug screening is one of the easiest and most reliable ways to obtain information on drug use. It can be performed quickly, so you can perform a point-of-care test and have some working knowledge of what is in that patient's urine when he or she leaves your office,” Ms. Snodgrass said.

When interpreting point-of-care test results, clinicians should assess the risk of false positives or negatives and should not make definitive decisions based on findings. If a urine drug test yields an unexpected finding, providers should limit the provision of the opioid to a 7- to 14-day period.

Clinicians should also be aware that some medication use or abuse may go undetected on a point-of-care test. Prescription drugs such as fentanyl, oxycodone, and carisoprodol are often omitted, certain opioid normetabolites may not react (typically <0.1%), and high thresholds are typically used in point-of-care tests.

“Take into account what's going on with the patient when you consider drug testing. If they are a higher-risk patient, then you should perform urine drug screening more often,” Ms. Snodgrass said.

Confirmation testing with more accurate methods such as GC/MS should be performed prior to making a final care decision, she advised.

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