The revolving door of opioid overdose

Experts offer advice on prescribing for patients who've overdosed.

As the opioid epidemic persists in the United States, hospitalists are on the front lines of care for patients who survive overdoses.

A particular challenge is that these patients often obtain more opioids. Ninety-one percent of first-time overdosers obtained another prescription within 2 years, usually from the same clinician, according to research published in the Jan. 5 Annals of Internal Medicine.

Photo by Thinkstock
Photo by Thinkstock

The consequences are grim. Patients who visit the emergency department more than once for opioid overdose are significantly more likely to be hospitalized and suffer near-fatal events, a 2014 Mayo Clinic Proceedings study found. And patients at greatest risk of overdosing usually got opioids by prescription, not from friends or family, according to a 2014 study in JAMA Internal Medicine.

“I think our article highlights a key potential pitfall from the fragmentation in our health care system,” said Marc LaRochelle, MD, MPH, lead author of the Annals study and a fellow at Harvard Medical School in Boston. “There is no clear mechanism to communicate known risk amongst providers. While we highlight several potential system improvements, until they are implemented, the burden lies on us as physicians to improve our communication amongst each other.”

Mandated reporting of prescription drug overdoses, better medical education on treating pain and addiction, and adequate time to evaluate patients could help prevent repeated overdoses, Dr. LaRochelle and others have noted. Hospitalists can also take a number of other steps to reduce repeated overdoses while optimizing analgesia when patients truly need it.

Essential steps

Physicians must make “every effort” to notify outpatient prescribers about overdose hospitalizations, said Charles Reznikoff, MD, FACP, a hospitalist and addiction medicine specialist at Hennepin County Medical Center in Minneapolis.

One way to do this is through prescription drug monitoring programs, which are now available in 49 states, Dr. LaRochelle added.

Patients' medication lists also need a careful look. “Common and obvious polypharmacy can contribute to overdoses,” said Dr. Reznikoff. “Sedatives and opioids are a classic dangerous combination.” Other likely suspects include high-dose opioids and renally cleared agents in patients with newly unstable renal function, he said.

Another step is to offer home rescue kits containing intranasal or injectable naloxone hydrochloride, an opioid antagonist that is FDA-approved for the emergency treatment of known or suspected overdose. Naloxone helps reverse opioid-associated respiratory depression and can be given safely by community bystanders after minimal training.

“In the emergency department, we are now starting to write prescriptions for the kit, or when possible, actually provide them to patients at discharge,” said Scott Weiner, MD, MPH, assistant medical director of emergency medicine at Brigham and Women's Hospital in Boston. “Many states also have waivers, so patients and family members can pick them up at pharmacies, even without a prescription.” Massachusetts, for example, permits pharmacies with standing naloxone orders to dispense kits without a prescription.

The most important step is to diagnose and treat addiction, several experts said. Whenever possible, hospitalists should evaluate and provide referrals to patients who need addiction treatment. “Addiction does not invalidate the patient's pain and is not incompatible with a simultaneous diagnosis known to cause pain,” Dr. Reznikoff emphasized. “You can be in pain with cancer and addicted to pain pills, and both diagnoses can be valid and require active management.”

Patients who accidentally overdose while abusing opioids probably meet criteria for a severe substance use disorder, added Corey Waller, MD, MS, a specialist in pain, addiction, and emergency medicine at Spectrum Health in Grand Rapids, Mich. Sending these patients home with opioids is very risky, but so is discharging them after detox without support, he added. “They will try and treat the withdrawal or ongoing pain, even if they are also trying to get off opioids,” he said.

For this reason, effective referrals are crucial. Some hospitals have in-house services to connect patients with methadone clinics, board-certified addiction medicine specialists, and primary care physicians who are authorized to prescribe buprenorphine or injectable naltrexone.

These pharmacologic treatments are best combined with cognitive or dialectical behavioral therapy, contingency management, facilitated 12-step modalities, or mindfulness-based therapy, Dr. Waller said. Applying the American Society of Addiction Medicine criteria also can help physicians select appropriate programs and assess the likelihood of comorbid disorders, he added. The criteria are online.

Detox and alternative analgesia

The Annals study on repeated overdoses did have some good news—patients who tapered off opioids, or had their doses cut to the equivalent of less than 50 mg of morphine a day, were significantly less likely to experience a repeated overdose than those prescribed higher doses.

A gradual taper is often the best approach for patients with chronic opioid abuse problems, Dr. Weiner emphasized. “Patients with chronic pain who overdose would likely not benefit from being abruptly cut off from their medications. I'm worried that patients who are abruptly cut off may be more likely to turn to heroin.”

Monitored detoxification regimens can blunt opioid withdrawal symptoms, but it is important to tell the patient that you will keep working with him or her to control pain, Dr. LaRochelle added. “There are many pharmacologic and nonpharmacologic modalities for treating pain beyond opioids, and each should be considered based on patients' individualized risk profile and medical conditions,” he said.

Patient characteristics should drive the choice of alternative analgesia, Dr. Reznikoff agreed. “In some cases, NSAIDs [nonsteroidal anti-inflammatory drugs] do as well in head-to-head trials against opioids. In other cases, they would be absolutely contraindicated.” Acetaminophen is mild but usually very safe, while tramadol is an opioid, not a safe alternative to opioids, he added.

Pain is not always patients' biggest issue, however. “Patients on hefty doses of opioids will go through withdrawal and craving when they stop, even if they are not addicted, per se,” said Dr. Reznikoff. “For these patients, all the NSAIDs in the world will not take them out of opioid withdrawal. When you look for alternative analgesia, you need to be very clear on what you are treating. Are you treating pain caused by tissue damage, or the emotional and physical distress of a patient detoxing from opioids?”

While tapers can help, there are no easy ways to manage withdrawal symptoms. However, physicians should challenge the notion that they are “somehow beholden to fixing all pain,” Dr. Reznikoff said. “This is the belief that has gotten us into this problem. Even if you believe it is your duty in general to treat all pain, and even if it is hard for you to offer nothing for pain, remember this is a person who is at very real risk of death. Primum non nocere.”

Dr. Weiner agreed. “Pain is a part of life, and the goal is to make the pain manageable but not eliminate it entirely. And we need to provide only the smallest amount of pain medication needed to achieve that aim.”

Staying on opioids?

There are a few situations where, even after an overdose, it is reasonable to continue opioids with close follow-up, such as when patients in acute pain overdose because of prescriber error. A short course of an abuse-deterrent opioid with a low diversion rate might be appropriate for these patients, said Dr. Waller.

Patients who are terminally ill or have conditions such as extensive burns or complicated trauma also might have such a strong indication for opioids that the benefits outweigh the risks, Dr. Reznikoff said. These patients, and those who overdose because of cognitive impairment, can benefit from pill boxes, home nursing visits, fewer pills, and more frequent follow-ups.

Infrequently, patients on long-term, medically indicated opioid treatment overdose because of new-onset renal insufficiency. They can be switched to renally safe opioids and discharged, one of the only cases when switching makes sense, Dr. Reznikoff said. “There is absolutely no evidence that rotating opioids reduces the risk of a future opioid overdose in someone who has had such an event already,” he added. “Lower the dose, don't change the medication.”

Patients who are switched to opioids with a relatively long duration of action need especially close follow-up until they reach steady state, he emphasized. A 2015 JAMA Internal Medicine study supported that advice, linking longer durations of action with increased risk of overdose, especially during the first 2 weeks of treatment.

Communicate to close loopholes

Some patients manipulate systemic loopholes to obtain opioids, the experts noted. They might evade current detection systems simply by switching clinicians or paying cash for prescriptions. Others might “explicitly or subtly imply that they will be an easier discharge and a less likely bounceback if they are given enough opioids,” Dr. Reznikoff said.

Physicians may also perceive that prescribing more opioids hastens discharge and prevents bouncebacks, while refusing to do so has the opposite effect.

“So to get through their day expeditiously, many doctors feel they need to give opioids, even when they do not think it is the medical thing to do. That's a shame,” said Dr. Reznikoff. Systems should be developed to provide specialized postdischarge care for overdose patients, as is done to reduce readmissions of heart failure patients, he suggested.

Until effective systemic changes occur, notifications and handoffs between shifts and health care settings are crucial. “Clear, consistent communication allows the patient to relax and focus on their health,” Dr. Reznikoff emphasized. “There is a spectrum of opioid behaviors among doctors, and there is no objective test for pain or addiction. So consistency is tough. But it is also one of the most important things in caring for these patients.”