OPIOID MISUSE, ABUSE, AND DIVERSION
Along with attempts to improve identification and treatment of pain, there has been an equal rise in prescription opioid addiction and abuse in the United States. Opioid misuse, abuse, and diversion are major problems with serious consequences.
Scope of the Problem
The National Institute on Drug Abuse (2022a) reports that:
- Among people ages 12 and older in 2020, an estimated 2.3 million people in the United States had a prescription opioid use disorder in the past year.
- Nearly 92,000 persons in the United States died from drug-involved overdose in 2020 due to illicit drugs and prescription opioids. The national overdose deaths involving prescription opioids among all ages in 2020 was 16,416.
- Among young people in 2021, an estimated 4.4% of 12th graders reported misusing any prescription drug in the past 12 months.
- 50,000 individuals used heroin for the first time, and 14,480 deaths from heroin occurred in 2020.
The state of Michigan ranks in the top third nationally for drug-related deaths, with over half due to synthetic opioids, mainly fentanyl.
- In 2020 there were 27.8 drug overdoses per 100,000 population in Michigan compared to 28.3 in the United States.
- In 2020 there were 2,186 opioid overdose deaths in Michigan, which accounted for 79.5% of all drug overdose deaths in the state.
- Prior to the pandemic, 0.4% of people age 12 or older reported opioid dependence or abuse in the past year.
(KFF, 2021; Michigan State University, 2020)
Drug diversion can be defined as any act or deviation that removes a prescription drug from its intended path from the manufacturer to the patient and can occur anywhere along the continuum: manufacturer, wholesale distributor, retail pharmacy, hospitals and other healthcare organizations, prescribers, healthcare professionals who administer the medication, or the patient for whom the medication is prescribed (ASHP, 2022).
The effort to prevent misuse, abuse, and diversion involves government and regulatory agencies, drug researchers and manufacturers, as well as healthcare institutions and individual clinicians.
CDC GUIDELINES FOR PRESCRIBING OPIOIDS
In 2022, the CDC updated its guidelines for prescribing opioids for the treatment of pain. Whereas the 2016 guideline focused on recommendations for primary care physicians, the newer guideline expands the scope to additional clinicians whose scope of practice includes prescribing opioids (e.g., physicians, nurse practitioners and other advanced-practice registered nurses, physician assistants, and oral health practitioners). (See “Resources” at the end of this course.)
Management of Opioid Overdose
Due to their pharmacologic effects, opioids in high doses can cause respiratory depression and death. Most drug-related deaths worldwide are attributable to opioids. An opioid overdose can be identified by a combination of three signs and symptoms, referred to as the opioid overdose triad, which include:
- Pinpoint pupils
- Unconsciousness
- Respiratory depression
Combining opioids with alcohol and sedative medication increases the risk of respiratory depression; and combinations of opioids, alcohol, and sedatives are often present in fatal drug overdoses (WHO, 2022).
It is important to consider opiate overdose or toxicity in a lethargic patient with no other identifiable cause. Care of the patient at the scene depends on the vital signs. If the patient is comatose and in respiratory distress, airway control must be obtained prior to any other action. Endotracheal intubation is highly recommended for all patients unable to protect their airways.
If there is a suspicion of opiate overdose, naloxone is administered to reverse respiratory depression. Naloxone, an opioid antagonist, rapidly reverses an opioid overdose. One should be aware that naloxone can also cause agitation and aggression when it reverses the opiate.
If the patient is a known drug abuser, the lowest dose of naloxone to reverse respiratory distress should be administered. In the ambulance, the patient may become combative or violent, and use of restraints may be required. If the individual has no intravenous access, naloxone can be administered intramuscularly, intranasally, intraosseous, or via the endotracheal tube. Data show that the intranasal route is as effective as the intramuscular route in the prehospital setting (Schiller et al., 2022).
Patient education includes showing patients, their family members, or caregivers how to administer naloxone. The medication can be given by intranasal spray or intramuscular, subcutaneous, or intravenous injection.
Patients given an automatic injection device or nasal spray should keep the item available at all times. The medication must be replaced when the expiration date passes and if exposed to temperatures below 39 °F or above 104 °F.
Naloxone is effective if opioids are misused in combination with other sedatives or stimulants. It is not effective in treating overdoses of benzodiazepines or stimulant overdoses involving cocaine and amphetamines (SAMHSA, 2021).
Side effects of naloxone may include an allergic reaction from naloxone, such as hives or swelling in the face, lips, or throat, for which medical help should be sought immediately. Use of naloxone also causes symptoms of opioid withdrawal. Opioid withdrawal symptoms include:
- Feeling nervous, restless, or irritable
- Body aches
- Dizziness or weakness
- Diarrhea, stomach pain, or nausea
- Fever, chills, or goose bumps
- Sneezing or runny nose in the absence of a cold
Since naloxone is a temporary treatment and its effects will wear off, medical assistance must be obtained as soon as possible after administering/receiving naloxone (SAMHSA, 2021).
MICHIGAN’S GOOD SAMARITAN LAW
Michigan’s Good Samaritan Law prevents drug possession charges against those that seek medical assistance for an overdose in certain circumstances. This law makes saving lives the priority during a drug overdose, not criminal prosecutions of illegal drug users (MDHHS, 2022).
Identifying Drug-Seeking Patients
Most patients who complain of pain are honestly seeking relief from discomfort. Others seek drugs in order to cope with addiction or to provide income. Differentiating between the two can be very difficult.
Drug seekers include people of every age, gender, and socioeconomic status. Often these people initially used prescription drugs for valid medical conditions, and drug-seeking behaviors may have developed as a result of disease progression, undertreatment of pain, tolerance to the medication, or unrecognized addiction. Only a small number of drug seekers do so to divert opioids for illicit sale.
There are some common characteristics that can provide clues to the prescriber of opioids regarding the nature of a patient’s intent. The patient who is drug seeking may:
- Come from a location that is far away, perhaps across state lines
- Have seen many doctors in a short period of time
- Present with specific complaints that are often subjective (back pain, headache)
- Bring old medical records they have been carrying around to many different doctors to get a pain prescription
- Use multiple pharmacies
- Claim an allergy to all pain medications except the one they are seeking as well as to diagnostic test contrast medium to avoid tests
- Suggest the medication, dose, and quantity being sought
- Be unwilling to consider any other treatments and does not want to listen to anything the clinician has to say
- Call or show up requesting a prescription at off hours, when the office is closing or right before the weekend/holiday when it is less likely their usual care provider(s) can be reached
- Lie or their story does not make sense (it is imperative to take a detailed history to look for inconsistencies in a made-up story)
- Exaggerate symptoms, with inconsistent behavior from waiting room to treatment room
- Become aggressive when different medications are suggested
- Give false information, such as a fake address or a disconnected phone number
- Be on multiple controlled substances, such as opioids and benzodiazepines
- Be excessively talkative, friendly, or helpful
However, drug-seeking patients with addictions are not the only ones who may engage in these behaviors. Over time, patients with true chronic pain can elicit some of these same behaviors (Girgis, 2021).
DRUG DIVERSION AND ADDICTION AMONG HEALTHCARE PROFESSIONALS
Because healthcare professionals are trusted with others’ health and well-being, they are not often suspected of drug addiction themselves; however, they are just as likely as anyone else to become addicted and are at a higher risk for addictive behaviors involving opioids because of their increased access to them.
It is a legal and ethical responsibility for healthcare professionals to uphold the law and to help protect society from drug abuse, and it is a professional responsibility to prescribe and dispense controlled substances appropriately, guarding against abuse while ensuring that patients have medication available when it is needed. Each healthcare professional also has a personal responsibility to protect their practice from becoming an easy target for drug diversion and must be aware of the potential situations where it can occur and the safeguards that can be utilized to prevent such diversion.
When the signs and symptoms of drug abuse are evident in a colleague, it is time to become concerned and involved, taking the following steps:
- Check the agency’s written drug and alcohol policy and follow recommendations.
- Document suspicions regarding the colleague, including any complaints, concerns, behavior patterns, or witnesses to behaviors.
- Bring concerns to management.
Addressing Pain in Individuals with Substance Use Disorders (SUDs)
Opioid use for pain management for patients with a history of SUDs may be considered if their use is carefully managed. This involves selecting the appropriate opioid, dosage titration, treatment agreements, and testing and monitoring. Medications should be started at a low dose to ease pain, then titrated to maintain pain relief without decreasing function or risking addiction or replace.
When patients develop tolerance to the analgesic effects of a particular opioid, providers can consider either escalating the dosage or switching from one opioid to another at a low dose that will effectively relieve pain without increasing the risk of relapse (SAMHSA, 2021).
Before introducing any opioids into a patient’s treatment regimen, an assessment is done to determine the patient’s risk for developing a substance abuse disorder (SUD).
Screening tools available to clinicians include:
- Opioid Risk Tool (ORT)
- Drug Abuse Screen Test (DAST-10 and DAST-20 for adolescents)
- Screener and Opioid Assessment for Patient with Pain-Revised (SOAPP-R)
- Brief Screener for Alcohol, Tobacco, and other Drugs (BSTAD)
These tools, however, commonly result in inaccurate findings and misinterpretations. For instance, since screening tools often rely on a patient’s self-report, a patient may falsify responses on questionnaires to avoid detection as a high-risk patient.
Other recommendations include drug testing, primarily urine screening. Drug testing offers a critical adjunct to clinical assessment of SUD risk. However, due to the ease with which samples can be adulterated, providers must carefully review their collection protocols and sample validation procedures to ensure optimal accuracy, which may require observed collection (NIDA, 2022; Rosenquist, 2022).