Category: Overdose

Hospital based opioid agonist treatment

Researchers in Canada have found a significant number of individuals with co-occurring mental health and substance use disorders are admitted to inpatient psychiatric units. We looked at those admitted to an acute care hospital in Vancouver, British Columbia, whom had been referred to an addiction medicine consult team, to develop a greater understanding of this population and of the care being provided in order to improve care outcomes and patients’ care experiences. (more…)

Pain Management with Opioids in 2019-2020

This JAMA Insights Clinical Update reviews evidence-based use of opioids to manage noncancer pain, proposing opioid-sparing pain management.  Based on recent literature and the rapidly evolving nature of the opioid overdose epidemic due to the emergence of fentanyl analogues in the illicit drug supply, there are clearly 3 main clinical scenarios being confronted by clinicians where evidence-based recommendations can be made. (more…)

America could relax opioid treatment access policies

Canada and the United States (U.S.) face an opioid use disorder and opioid overdose epidemic.

The most effective OUD treatment is opioid agonist therapy (OAT). It means buprenorphine (with and without naloxone) and methadone. Although federal approval for OAT occurred decades ago, in both countries, access to and use of OAT is low. Restrictive policies and complex regulations contribute to limited treatment access. (more…)

Why most opioid risk tools fail?

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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