Category: Naloxone

Why equity hinders effective pain relief for opioid naive people

Equitable access to care is problematic; some people get it, most are left out.

The REDONNA study (https://doi.org/10.1016/j.cct.2021.106462) began from the motivation for equitable opioid prescribing in primary care. It aimed to provide prescribing non-judgmental feedback to physicians using audit & feedback letters developed by the @Drug_Evidence and @DrRitaMc @malcolmlaclure

 

They received information about the number of new opioid initiations & how they compared to the average physician. They were provided information on the (lack) of effectiveness on pain for opioid naïve patients through educational webinars: https://doi.org/10.1093/fampra/cmac044

 

From this study, we hope to support the uptake of quality prescribing practices that are equity-oriented and evidence-based to help patients manage pain.

Equitable care saves lives

This includes equitable prescribing for individuals who use opioids in addition to medical education that goes beyond and amplifies the message of international @OverdoseDay  #IOAD2022 #endoverdose

Special thanks to @ShawnaNarayan for coordinating REDONNA and crafting educational messages.

Newly started primary care opioid prescriptions plateaued in 2018-2019

Our new study published in the Canadian Journal of Addiction found plateauing rates of new starts of opioid analgesics in British Columbia in 2018-2019. We wanted to find out how many and what kind of opioid prescriptions were started to opioid naïve patients by family physicians in British Columbia. (more…)

Hospital based opioid agonist treatment

Researchers recently found that many people with co-occurring mental health and substance use disorders are admitted to inpatient psychiatric units. According to a 2019 report from the Boston’s Institute for Healthcare Improvement and The Grayken Center, “hospitals have the opportunity to make a major impact in reducing morbidity and mortality related to opioid use.” The present study, therefore, looked at patients admitted to an acute care hospital in Vancouver, British Columbia. It sought to improve our understanding of this population and the care provided so that we can improve patients’ outcomes and care experiences.

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Why most opioid risk tools fail?

ruler

How many of you had a flu this winter? Anyone took antibiotics for that? But some people can’t take them because they are allergic.  Now, imagine someone suffering from pain, being prescribed opioids and having a negative reaction to them. What if this reaction was addiction to opioids? What if we could measure the risk for addiction the same way we can measure allergy to antibiotics? This article describes why opioid addiction is not an allergy to opioids and that we should not think about it that way, nor try to measure it using opioid risk tools.

The Problem

We wanted to find out whether we can tell which adult will go into opioid addiction when prescribed opioids for pain. Why? Prescription opioid addiction can have devastating consequences but it is not clear how to identify patients with pain among whom prescription opioids can be safely prescribed.

The Study

The Journal of the American Medical Association – JAMA Network Open – commissioned us to do a very special kind of review that is called Diagnostic Accuracy Review. For this study, we chose only the best studies. To illustrate diagnostic performance, data from higher quality studies were extracted and used to calculate likelihood ratios (LR). What are likelihood ratios? Likelihood Ratios bigger than 1 increase the probability of a disease. Likelihood ratio of 1 equals roughly zero increase. Likelihood of 2 equals just about 15% increase.

Opioid Risk Tools

The opioid risk screening tools that are in widespread use are based on low quality studies and are not helpful in identifying patients at higher risk. Among them, the pain medication questionnaire had likelihood ratio of 2.6 (slight increase in likelihood, about 15%). Some risk factors were found in a single high quality study:

A history of opioid or non-opioid use disorder, a mental health diagnosis and concomitant prescription of certain psychiatric medications may increase the risk of prescription opioid addiction.

However, only the absence of a mood disorder appeared useful for identifying lower risk patients (and assessment tools incorporating combinations of patient characteristics and risk factors were not useful).

Take home?

There are few valid ways to identify patients who can be safely prescribed opioid analgesics. Given the lack of good tools and the mounting evidence that opioids are not effective for chronic pain, such as the recent JAMA trial called Space, prescribers should be aware of tools’ limitations when prescribing opioids for pain. Opioid addiction is not an allergic reaction. Don’t try to measure risk for it and whether it’s safe to prescribe. De-implement opioid risk tools!

 

Reference: Klimas, J., Gorfinkel, L., Fairbairn, N., Amato, L., Ahamad, K., Nolan, S., Simel, D., Wood, E. (2019) Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: A Systematic review. JAMA Network Open. 2(5):e193365. Doi: 10.1001/jamanetworkopen.2019.3365

If you enjoyed reading this article, you may also wish reading the article about diagnosing opioid use disorder link here

Diagnosing opioid addiction in people with chronic pain

Training medical students in addiction medicine can help in the opioid crisis

Naloxone

Better medical education is one solution to the opioid overdose crisis, but our new study suggests that few students have direct experience of overdose management although many have been exposed to patients using opioids.

Every year, more people die in Ireland due to opioid overdoses than in car accidents. Over 200 overdose deaths occur annually in Ireland. Naloxone is an effective treatment; lay people can use it. We surveyed 243 undergraduate medical students doing their final professional completion module before graduating from University College Dublin. This survey showed that medical students commonly encounter patients with opioid use disorders and want more naloxone training in the medical school.

Overdose prevention and management, including naloxone provision, should be a priority for health education.

A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of opioid use disorder care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).

Over half of the medical students supported wider naloxone availability and its lay distribution to address the growing overdose problem in Ireland.

Most students had taken a history from a patient with an opioid use disorder and a third had witnessed at least one opioid overdose.

Few students had direct experience of overdose management although many met patients using opioids.

High level of student exposure to patients using opiates suggests we have an opportunity to increase addiction content in medical curricula.

Educate students

Medical school offers limited addiction medicine education. Medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdoses.

Tobin, H., Klimas, J., Barry, T., Egan, M., Bury, G. (2017, In Press) Opiate Use Disorders and Overdose: Medical Students Experiences, Satisfaction with Learning and Attitudes toward Community Naloxone Provision. Addictive Behaviors.