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.
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 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).
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
Looking at an old drug repurposed to treat opioid addiction, a new study found long-acting formulation of morphine (SROM) promising for curbing the opioid epidemic.
Many people who overdose on fentanyl have untreated opioid addiction. Left untreated, opioid addiction can have devastating consequences. One of the reasons for the low treatment rates is that current medications have limited ability to retain people in treatment. The Canadian National Guideline for the Clinical Management of Opioid Use Disorder recommends treatment with slow-release oral morphine, also known as SROM—prescribed as a third line of therapy. In this study, we wanted to compare Kadian® and Methadone for the treatment of opioid use disorder.
|QUICK FACT: Slow release oral morphine (SROM) is given once daily and has been proposed for people who do not tolerate or respond to methadone.|
We looked at the scientific literature up until the May of 2018. Then, we wanted to see if SROM (brand name Kadian®) works as well as methadone in the treatment of opioid use disorder. In the study, we included people of any gender, age or ethnicity.
What did the study find?
We found four unique clinical trials that met inclusion criteria (n = 471), and compared Kadian® with methadone. Meta-analysis of existing clinical trials suggests SROM (slow release oral morphine) may be as effective in retaining patients in treatment and reducing heroin use.
This is the first meta-analysis of slow release oral morphine (Kadian®). We included new studies that increase the validity of the study. We included previously unpublished data obtained from primary trials. A pooling of data for craving and adverse events was not possible due to inconsistent reporting of outcome measures across trials
SROM seems as good as methadone for the treatment of opioid use disorder but retains people in treatment longer.
Why is SROM important?
While methadone is effective for many patients, these findings suggest SROM may provide benefits in addressing some of the limitations of methadone. We need to expand uptake and retention of people on opioid use disorder treatments. These data should compel public health agencies and decision makers to find therapeutic tools for people who have opioid addiction.
We are running out of options for helping people overcome opioid addiction and abandon contaminated fentanyl. But revisiting this medication, known from cancer treatment, can have a dramatic impact on addiction treatment success because it is not only equally effective as the current treatment options but also better tolerated by patients. Expanding treatment options responds to patients’ needs by offering drugs with fewer side effects.
Kadian® slow-release oral morphine is available in 10mg, 20mg, 50mg, and 100mg capsules, which may be combined as necessary.
|Reference: Klimas, J., Gorfinkel, L., Giacomuzzi, S., Ruckes, C., Socias, E.M., Fairbairn, N., Wood, E. (2019) Slow Release Oral Morphine versus Methadone for the Treatment of Opioid Use Disorder: A Systematic Review and Meta-Analysis. BMJ Open (In Press) 0:e025799. doi:10.1136/bmjopen-2018-025799|
If you enjoyed reading this blog, you may also enjoy reading about a medication for treatment of stimulant use disorder. Link here
Which student learns best with hospital teams fighting opioid crisis? Understanding how students learn is perhaps the most important way to improve addiction training.
In a new article published by the Substance Abuse journal, we report findings suggesting that the completion of an elective with a hospital-based Addiction Medicine Consult Team appeared to improve knowledge of medical students more than of other types of students. Read more below or listen to the podcast.
Firstly, we found that both emerging and established physicians appear to be responsive to this type of training. Secondly, the learner self-assessment can provide valuable feedback to the consultants. Then, consultants can focus more on the students who learn less.
Keep fighting opioid crisis through training
The study sample was drawn from medical students, residents and physicians who took part in a month-long rotation with a hospital-based addiction medicine consult team in Vancouver, Canada. The addiction rotation includes full-time clinical training involving intake assessment and treatment planning. And referrals to community agencies and starting people on evidence-based medications for substance use disorders. The students take part in didactic lectures, bedside teaching, journal clubs and some prepare papers for submission to peer-reviewed journals. Each year, about 80 learners go through the program. Furthermore, learners rate their knowledge before and after the training.
At the end, all learners reported increased knowledge. One group, however, learned more than the others – the medical students. This two-year study confirms that a structured clinical training program can lead to an increased knowledge on addiction and that medical students benefit from it the most.
For more info read the full article at:
Gorfinkel, L., Klimas, J., Ahamad, K., Mead, A., McLean, M., Fairgrieve, C., Nolan, S., Small, W., Cullen, W., Wood, E., Fairbairn, N. (2019) In-hospital training in addiction medicine: A mixed methods study of health care provider benefits and differences. Substance Abuse (Published online Jan 28) doi: 10.1080/08897077.2018.1561596
If interested, you can also read: What can hospital teams teach medical students about addiction to help curb the opioid overdose epidemic?
Or visit a post that talks about this research as it was presented at the Canadian Society for Addiction Medicine link here
Celebrating 30 years of CSAM-SMCA in Vancouver, BC, the conference focused on: Crisis, Controversy & Change. What is the role of education in tackling the overdose crisis?
Three speakers at the education session on Friday offered several potential solutions.
Friday, October 26th: Medical Education in Addictions (CSAM-SMCA Education Committee)
(1:30) Who Learns the Most about Addictions in Hospitals? A Mixed Methods Study.
Jan Klimas (representing a co-author team: Gorfinkel, L., Ahamad, K., Mead, A., McLean, M., Fairgrieve, C., Nolan, S., Small, W., Cullen, W., Wood, E., and Nadia Fairbairn), summarised the results of a 2-year evaluation of the addiction medicine consult team in the St Paul’s hospital, Vancouver, British Columbia. Learners, such as medical students, completed web surveys before and after their clinical placements with the team. A purposeful sample participated in post-elective interviews. Results of this research study will soon appear in a paper accepted for publication in the Substance Abuse journal.
(1:45) Addiction Medicine Mentorship: Capacity Building Through Relationship Building.
Kate Hardy (Manager) and Sarah Clarke (Sarah Clarke) from the Metaphi mentoring project spoke about the role of primary care providers in the treatment of substance use disorders. The length of the treatment is more important than the intensity. Patients prefer to be treated in primary care. Integrating mental health with physical health services creates better outcomes. Primary care has greater capacity for treatment. But many providers are not willing to take over the care of persons with SUD. Medical mentoring of primary care providers by specialists. There’s no wrong door to access the addictions treatment. Mentorship, such the one provided via Hardy’s and Clarke’s project – metaphi – must be easy and convenient, sufficiently incentivized. Check out the project website www.metaphi.ca.
(2:00) The ABC’s of Addiction Fellowship Programs in Canada.
Melanie Willows (introducing her co-author team: Anees Bahji, Annabel Mead, Nikki Bozinoff, Ron Lim, Lydia Vezina, Ronald Fraser & Kim Corace) and a group of fellowship directors facilitated a session, which was sponsored by the CSAM education committee, about the Canadian fellowships in addiction medicine and offered recommendations for the future of the training programmes in Canada. In addition to the fellowship directors, the talk started with a lived experience of someone who has been accepted to the fellowship but who has not started the fellowship. A recent fellowship alumna concluded the group presentation.
If you enjoyed reading about this year’s CSAM 2018 conference, you can read about the CSAM 2015 here
Will an increasing pressure on prescribers curb the rising opioid overdose rates?
With only 0.5% of patients prescribed opioids reportedly developing addictions, there must be something else going on that’s making people overdose. A mismatch. Research on this topic is messy and patchy–– simply put, the large correlational research and incidence studies of addiction do not match up. In a recent commentary, we outline how prescription opioids might indirectly influence the rising overdose and addiction rates.
Mismatch: Why Correlation and Incidence Might Not Match Up
First, diversion gets medically prescribed opioids (MPOs) to those who are not prescribed the medication. Diverted MPOs can be sold, gifted (mostly to family members or friends), stolen, or sometimes obtained through “doctor shopping”, where patients get the same prescription from multiple physicians. But we don’t know how much diversion is due to sold, gifted or stolen medicines. How much do the different diversion types contribute to addiction and overdose? And for that matter, how much is diversion occurring, and to what extent is it contributing to national opioid crises?
Second, because overdose is often preceded by addiction, many researchers have focused on the persons who develop an addiction when prescribed opioids. However, if addiction doesn’t come before overdose, some high-risk patients go unstudied, and thus unreported. This has been shown in some states, such as West Virginia, where prescription opioids contributed to 93% of overdose deaths and very few of the deceased had iatrogenic addiction. So, some people might be at risk of sudden overdose but are missed in research studies that focus on medical diagnoses of addiction. This gap in the research is likely due the difficulty of studying overdose risk without the presence of addiction.
Polydrug use and overdose
Third, polydrug use may lead to overdose in people who use prescription opioids but do not specifically have addiction to their MPO. Here benzodiazepines are a big issue. It is important to note that many studies of addiction to MPOs do account for polydrug use by incorporating urine drug screens; however, positive results are often lumped together with other “aberrant” behaviours such as failed pill counts or requesting opioids from multiple doctors. Ultimately, we can’t tell how much polydrug use is really leading to addiction or overdose in this context.
Finally, it is possible that incidence studies to date could be misrepresenting the true risk of addiction to MPOs. Studies of OUD incidence in pain care use definitions of addiction that range from very broad to highly specific, mixing up terms like “dependence”, “abuse”, “misuse”, or “problematic use”. This could make it so our guesses about the risk of addiction to MPOs are muddled, leading to skewed results.
We need to understand better if reduced opioid prescriptions can reduce the opioid crisis. Then we can make the change happen.
To read the whole commentary, please visit the journal website www.canadianjournalofaddiction.org or lookup the paper using the following citation:
Gorfinkel, L., Wood, E., Klimas, J. (In Press) Prescription opioids, opioid use disorder, and Overdose Crisis: Current Dilemmas and Remaining Questions. (Published ahead of Print, June 4th) Canadian Journal on Addiction
I thank Lauren Gorfinkel for feedback on this post.
If you enjoyed reading this post, you may also like my poem about pain. See link below: