Safe Opioid Use

Since opioids are a controlled substance which carry many risks, they must be safely prescribed and monitored for safe use.1 High-risk patients or those with long-term opioid prescriptions should be monitored based on an interval decided by the clinician or larger care team.2 It can also be outlined in the pain agreement, for example that a patient will be adherent with follow-up visits once a month, or every three months.2 In order to make sure that patients comply with visits, there can be rules around prescriptions and follow-up appointments. For example, prescriptions can be filled to last until the appointment date, and can only be refilled in person.2 The clinician can also review PDMP databases to see if any patients have received prescriptions from other doctors.2

Patient and caregiver education

Prior to initiation of any opioid therapy, clinicians must have conversations with patients about the risks of dependence, addiction, and overdose.3 If necessary, the clinician should share this information with any caregiver(s) or the patient’s family.4 The clinician should also describe adverse effects of opioids, which are commonly nausea and constipation, drowsiness, lethargy, and pruritus, followed by vomiting, and less frequently respiratory depression and behavioral changes caused by certain types of opioids (eg, morphine).5

Other conversations about opioid safety should include risks concurrent substance use especially sedating drugs. Mixing opioids with other prescriptions, alcohol, and over-the-counter medications can result in overdose.7 Overdoses may be fatal if opioids are mixed with anxiety medications, such as Benzodiazepine (eg, alprazolam or diazepam).7 If the patient had a past SUD and is in complete recovery, the clinician should also address the risk of relapse.

Proper storage and disposal

Some opioids are administered in ways that can be dangerous to other household members or young children.8 For example, fentanyl transdermal system is a patch applied to the skin that treats opioid-tolerant patients by releasing fentanyl on a continuous basis.9 However, children can accidentally play with or use this patch unintentionally and absorb dangerous amounts of fentanyl into their system. Other similar examples include fentanyl lozenges or brightly colored fentanyl pills.10 Regardless of the route of administration, all opioids should be stored in a safe and secure location (preferably locked) out of reach from any young children.11 Medications should never be shared, and patients should be encouraged to explain the risks of opioids with household members.11

Any expired, unused, used, or unwanted medications (whether they are patches, pills, or another form), should be safely and promptly disposed. Safety measures include removing or scratching out identifying information from prescriptions prior to disposal.13 Common disposal sites are mail-back programs, medication drop boxes, and “take back” programs at local sites/pharmacies.13 The clinician should share all of these safety and disposal options with the patient prior to opioid initiation.

Opioid overdose

An overdose can occur if a person takes an extra dose either intentionally or accidentally.14 It can also occur if there is opioid misuse, or if it is used in a way not prescribed by the physician.14 Opioid overdose requires emergency medical attention and 911 must be called.14 If available opioid overdose reversal drugs should be immediately given.14 Signs of an opioid overdose include when a person doesn’t wake or is unresponsive, has a limp body, purple or bluish color fingernails or lips, makes vomiting or gurgling noises, or has slow breathing or heartbeat. CPR can be administered if breathing has slowed or stopped.14 A non-fatal, opioid overdose may result in opioid-induced respiratory depression, and more serious complications, such as brain injury.15

Nalmefene is an FDA-approved opioid overdose reversing nasal spray, however it is by prescription only and intended for use in healthcare settings.14 Naloxone is another FDA-approved medication that can quickly reverse an opioid overdose, including prescription and illicit opioids, provided it is administered in time.14 Naloxone is small, easy to carry, and can be used by anyone without medical training. It can come as a nasal spray or an injectable, and just takes one dose for a person’s breathing to return to normal (after 2-3 min).16

How to use naloxone spray17

How to use injectable naloxone17

Patients at risk of opioid use disorder or with a past or current SUD should keep naloxone at home and let family members and caregivers know where to find it in the event of an overdose.18 People prescribed a high dose of an opioid (>50 morphine milligram equivalents per day) should also keep naloxone at home or carry it with them.17 It is necessary that the person receives emergency medical attention as soon as possible after administering Naloxone (or Nalmefene).16 Clinicians can co-prescribe naloxone for patients with high-dose opioid prescriptions or at-risk patients.16 Clinicians should also share that naloxone can cause opioid withdrawal-like symptoms after use.19

References

  1. Horn DB, et al. Responsible controlled substance and opioid prescribing. StatPearls. Last updated October 22, 2023. https://www.ncbi.nlm.nih.gov/books/NBK572085/
  2. Hudson S, Wimsatt LA. How to monitor opioid use for your patients with chronic pain. Fam Pract Manag. 2014;21:6-11.
  3. Thakur T, et al. Communication between patients and health care professionals about opioid medications. Explor Res Clin Soc Pharm. 2021;2:100030.
  4. American Society of Addiction Medicine (ASAM). ASAM Opioid Patient Guide. 5/2020. https://eguideline.guidelinecentral.com/i/1275542-asam-opioid-patient-guide-2020/5?
  5. Paul AK, Smith CM, Rahmatullah M, et al. Opioid analgesia and opioid-induced adverse effects: A review. Pharmaceuticals (Basel). 2021;14:1091.
  6. Fraser Health Authority. Recognizing an overdose. August 25, 2015. https://www.fraserhealth.ca/health-topics-a-to-z/mental-health-and-substance-use/overdose-prevention-and-response/recognizing-an-overdose
  7. Substance Abuse and Mental Health Services Administration (SAMHSA). What is Opioid Overdose? March 29, 2024. https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/opioid-overdose
  8. Gaw CE, et al. Characteristics of fatal poisonings among infants and young children in the United States. Pediatrics. 2023;151:e2022059016.
  9. US Food and Drug Administration (FDA). Accidental Exposures to Fentanyl Patches Continue to Be Deadly to Children. May 18, 2023. https://www.fda.gov/consumers/consumer-updates/accidental-exposures-fentanyl-patches-continue-be-deadly-children
  10. Drug Enforcement Agency (DEA). DEA Warns of Brightly-Colored Fentanyl Used to Target Young Americans. Published August 30, 2022. https://www.dea.gov/press-releases/2022/08/30/dea-warns-brightly-colored-fentanyl-used-target-young-americans
  11. American Medical Association (AMA). 5 tips for safely storing opioids at home. Published September 6, 2018. https://www.ama-assn.org/delivering-care/overdose-epidemic/5-tips-safely-storing-opioids-home
  12. Mississippi State University (MSU). Prescription Opioid Misuse. September 6, 2018. https://extension.msstate.edu/health/the-promise-initiative/prescription-opioid-misuse
  13. Drug Enforcement Administration (DEA). How To Properly Dispose of Your Unused Medicines. Last updated April 2, 2024. https://www.fda.gov/consumers/consumer-updates/where-and-how-dispose-unused-medicines
  14. Substance Abuse and Mental Health Services Administration (SAMHSA). What is Opioid Overdose? Published March 29, 2024. https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/opioid-overdose
  15. US Food and Drug Administration (FDA). FDA updates prescribing information for all opioid pain medicines to provide additional guidance for safe use. April 13, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-prescribing-information-all-opioid-pain-medicines-provide-additional-guidance-safe-use
  16. US Food and Drug Administration (FDA). Access to Naloxone Can Save a Life During an Opioid Overdose. March 3, 2023. https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose
  17. Centers for Disease Control and Prevention (CDC). Lifesaving naloxone-Stop Overdose. April 2, 2024. https://www.cdc.gov/stop-overdose/caring/naloxone.html
  18. Centers for Disease Control and Prevention (CDC). What You Need to Know About Naloxone: Fact Sheet- Family and Caregivers. April 2024. https://www.cdc.gov/overdose-prevention/media/pdfs/2024/04/Naloxone-Fact-Sheet_FamilyandCaregivers_WhatYouNeedToKnow_4_11_2024.pdf
  19. National Institute on Drug Abuse. Naloxone DrugFacts. February 12, 2024. https://nida.nih.gov/publications/drugfacts/naloxone

All URLs accessed August 15, 2024.

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