Category: Poly-drug use

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

As good as methadone if not better

equal

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

How can we do better job in studying Topiramate?

Updating alcohol Cochrane literature review

Cochrane

Updating Cochrane systematic reviews makes them most useful and fresh for readers. We updated our review on concurrent alcohol and drug problems again.

Cochrane podcast

Which new studies we found?

We found seven studies that examined 825 people with drug problems. Six of the studies were funded by the National Institutes for Health or by the Health Research Board; one study did not report its funding source.

One study focused on the way people think and act versus an approach based on Alcoholics Anonymous. It aimed to motivate the person to develop a desire to stop using drugs or alcohol.

Three studies looked at a counselling style for helping people to explore and resolve doubts about changing their behaviour (group, individual and intensive formats). Their controls were education, or less intensive counselling, or assessment-only.

Two Irish studies and one Swiss study looked at practices that aimed to identify an alcohol problem and motivate the person to do something about it versus usual treatment.

This study has been made into a podcast available at Cochrane.org news item at https://www.cochrane.org/news/podcast-which-talking-therapies-work-people-who-use-drugs-and-also-have-alcohol-problems

and a Network news item https://mhn.cochrane.org/news/podcast-which-talking-therapies-work-people-who-use-drugs-and-also-have-alcohol-problems Listen to the podcast below:

Updating Cochrane Review – Key results

The Swiss and Irish studies were directly compared. They took place in general practices (one trial) or methadone clinics (two trials). They included 170 participants with a mean age of 37 years. All participants had positive alcohol screening test upon entry to the trial. At the end, the scores between groups were similar (average difference in scores: -0.6, 1.7 and -2, respectively).
One study found that a brief motivational intervention led to a reduction of alcohol use (by seven or more days in the past month at 6 months).

It remains uncertain whether talking therapies affect drinking and drug-using in people who have problems with both alcohol and other drugs. We lack high quality studies.

Cited cochrane review: Klimas J, Fairgrieve C, Tobin H, Field C-A, O’Gorman CSM, Glynn LG, Keenan E, Saunders J, Bury G, Dunne C, Cullen W. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database of Systematic Reviews 2018, Issue 11

Read a summary of the previous version of this review here

Which talking therapies work for drug users with alcohol problems? A Cochrane update

Diagnosing opioid addiction in people with chronic pain

Diagnosing opioid addiction

Diagnosing opioid addiction in people with chronic pain requires a fully validated alternative to DSM-5.

Over the past two decades, a steep rise in the number of opioids dispensed for pain treatment has been accompanied by a dramatic rise in overdose deaths in the United States. In 2016, up to 32 000 deaths reportedly involved prescription opioids. Besides that, the economic burden of prescription opioid overdose exceeds $78bn (£59bn; €67bn) annually.

Despite all the evidence of harm, it remains unclear exactly how to determine if a patient with chronic pain has opioid addiction. What criteria should serve as a gold standard in making a diagnosis of opioid use disorder (OUD) in this context? This is an important gap in the literature. It hinders both evidence based care and research on the links between prescription opioids and OUD. Therefore, we discuss the limitations of diagnosing OUD in people with chronic pain, and make several recommendations for further research.

Diagnosing opioid addiction in people with chronic pain

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides a widely used set of diagnostic criteria for OUD. But these criteria do not always apply to patients who are prescribed opioids for chronic pain. According to DSM-5, if a patient presents with 2 out of 9 specific symptoms, it may indicate …

Source:

Gorfinkel LaurenVoon PaulineWood EvanKlimas JanDiagnosing opioid addiction in people with chronic pain 

The opioids and addiction mismatch

hammer and spanner mismatch

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?

We need to start accepting that biological factors are a part of this picture

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: