Opioid Guidelines and Their Implications for Occupational Therapy
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Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-8 for details. Opioid Guidelines and Their Implications for Occupational Therapy Niccole Carpenter Rowe, BA, COTA/L chemical modifications to naturally occurring opium alkaloids. Pain Consultants of East Tennessee The term opioid is commonly used to include the whole family of Knoxville, Tennessee legal and illicit opioids and opiates. Prescription opioids are most commonly used for treating pain and include opiates, synthetic Kimberly Lowe Breeden, MS, OTR/L opioids, and semi-synthetic opioids (see Table 1 on p. CE-2). Pain Consultants of East Tennessee Because of media attention to the increasing cases of opioid Knoxville, Tennessee abuse and addiction, some patients with pain may be concerned that they will inevitably become addicted if they take opioids. This CE Article was developed in collaboration with AOTA’s For others, it might be merely the stigma associated with taking Rehabilitation and Disability Special Interest Section. prescription opioids that prevents them from considering this option. As Carol Levy (2018) states in an editorial about her resistance to taking opioids despite her chronic pain: “They’ll ABSTRACT think I am an abuser or an addict.” This article provides information about recent federal guidelines Long-term opioid use does not necessarily lead to physical regarding prescribing opioids and treating chronic pain, to help dependence, which is distinct from addiction disorder (National occupational therapy practitioners improve treatment related Institutes of Health, 2011). The Centers for Disease Control and to chronic pain as well as better promote occupational therapy’s Prevention (CDC; 2016) defines long-term opioid use as “use of distinct role in achieving the objectives in the guidelines. opioids on most days for more than 3 months” (p. 8). Physical dependence is the process by which the body adapts to a specific LEARNING OBJECTIVES drug and manifests “drug-class specific withdrawal syndrome After reading this article, you should be able to: that can be produced by abrupt cessation, rapid dose reduction, 1. Recognize the implications of national guidelines regarding decreasing blood level of the drug, and/or administration of an treating chronic pain that affects the delivery of occupational antagonist” (Corsini & Zacharoff, 2011). therapy services 2. Describe the biopsychosocial model for chronic pain man- Addiction is: agement using an interdisciplinary approach [A] disease of brain reward, motivation, memory, and 3. Differentiate between opioid use disorder and chronic pain related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and INTRODUCTION spiritual manifestations. This is reflected in an individual In the United States, more than 116 million individuals are pathologically pursuing reward and/or relief by substance dealing with chronic pain (Seth et al., 2018). In 1991, advocacy use and other behaviors. (American Society of Addiction for improved treatment for pain began (Tsang et al., 2008). Medicine, 2011, p. 1) One result of these efforts may have been the inadvertent rise in prescription opioid overdose deaths by more than four times from 1999 to 2016 (Seth et al., 2018). In response to this crisis, Too often, people are not aware of the differences in government and health-regulating entities have created guide- individuals’ adaptations to a drug and its connection to drug lines regarding the prescription of opioid pain relievers. These addiction. For prescribers, the challenge is to ensure safety regulations have affected not only health care providers, but with medication use and to minimize the risk of addiction. One also people with chronic pain, often leading to their frustration, way to do this is to assess and monitor for aberrant behaviors, anger, confusion, and concerns about treating their pain. which are any medication-related behaviors that depart from strict adherence to the prescribed plan of care. These behaviors DEFINING THE RELEVANT TERMS include abuse, which is using a drug for nonmedical purposes; An opiate is the alkaloid that occurs naturally in opium and is diversion, which is intentionally removing a medication from derived from the opium poppy. An opioid is a product that binds legitimate distribution, including sharing it with friends or fam- to the same receptors as opiates. Synthetic opioids are those that ily members or selling it on the street; misuse, which is taking are chemically manufactured, whereas semi-synthetic opioids are medication in a way other than how it was prescribed (possibly WWW.AOTA.ORG ARTICLE CODE CEA0618 CE-1 Continuing Education Article Download the CE Exam Click here to purchase and take the exam for CE credit. Table 1: Brand Name and Generic Versions of Various Types of Opioids Type of Opiod Brand Name Generic Opiates MS Contin Morphine Duramorph Codeine Semi-synthetic Hysingla ER Hydrocodone Zohydro ER OxyContin Oxycodone Roxicodone Dilaudid Hydromorphone Opana Oxymorphone Numorphan Butrans Buprenorphine Synthetic Nycynta Tapentadol Methadose Methadone Dolophine Demerol Meperidine Actiq Fentanyl Duragesic Ultram Tramadol Darvon Propoxphene Combination Drugs Percocet Acetaminophen and oxycodone Roxicet Targinq Oxycodone and naloxone Lortab Hydrocodone and acetaminophen Vicodin unintentionally, such as forgetting to take it or taking it incor- RECENT GUIDELINES rectly); and overdose, which is taking a lethal or toxic amount of Concerns over the increase in adverse events from prescription a medication. opioids, along with an agenda to improve pain care, have led to many federal government, state government, and health care HISTORY AND PREVALENCE OF THE OPIOID CRISIS agencies publishing guidelines for prescribing opioids and treat- In the early 1990s, the American Pain Society began to advo- ing pain. This article discusses four recent guidelines, including cate for new quality assurance standards for acute and cancer their background, purpose, and recommendations relevant to pain. These standards were based on an editorial in the Annals occupational therapy practitioners. of Internal Medicine that promoted using opiate analgesics for treating pain, and stating that the risk of addiction was low. This Relieving Pain in America (2011) determination was based on a single study (Baker, 2017). As a In 2010, the Patient Protection and Affordable Care Act charged result, in 2000, the Joint Commission required all patients to HHS with examining pain as a public health problem in the be assessed for pain (Morone & Weiner, 2013). Congress then United States in partnership with the Institute of Medicine of declared a “Decade on Pain Control and Research,” from 2001 the National Academies (IOM; 2011) to determine how pain to 2011. After these and other public health efforts, there was was being researched, treated, and discussed in the United an increase in not only prescribing opioids, but also in reports States. The IOM published the result of this collaboration, of misuse, addiction, and overdose deaths (U.S. Department of Relieving Pain in America: A Blueprint for Transforming Prevention, Health and Human Services [HHS], 2016). Care, Education, and Research, in 2011. This document provides CE-2 ARTICLE CODE CEA0818 AUGUST 2018 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-8 for details. recommendations to transform how health care providers Guideline Recommendations for Safer Prescribing Practices understand, assess, treat, and prevent pain, including calling for The FDA and CDC focus on reducing risks associated with another set of guidelines to be developed that provides a “com- prescribing opioids. The FDA (2018) believes that health care prehensive, population health-level strategy for pain preven- practitioners should have an understanding of alternate pharma- tion, treatment, management, education, reimbursement, and cologic (non-opioid) and non-pharmacological treatments for research” (IOM, 2011, p. 7). pain so opioids are considered when those alternate treatments are inadequate. The CDC states that these alternate treatments National Pain Strategy (NPS; 2016) are preferred for chronic pain over opioid medication. The Interagency Pain Research Coordinating Committee There are also specific recommendations for actions to be (IPRCC) created the National Pain Strategy: A Comprehensive taken if opioids are prescribed. The CDC states that the prescriber Population Health-Level Strategy for Pain at the request of the should follow up with the patient within 4 weeks of initial pre- HHS to develop strategies and further recommendations based scription or if there is a change in dosage. During that follow-up, on the initial findings of Relieving Pain in America. The NPS the prescriber should reassess the patient’s function, pain, and seeks “to reduce the burden of pain for individuals, their fami- quality of life; monitor side effects; and check for signs of aber- lies, and society as a whole” (IPRCC, 2016, p. 6). For each of its rant behaviors or misuse (Dowell et al., 2016). For long-term objectives, the NPS identifies short-, medium-, and long-term opioid prescriptions, the CDC recommends a reassessment at strategies; federal stakeholders in the objective; possible collab- least every 3 months. The FDA does not specify reassessment fre- orators to achieve the objective; and metrics for determining quency, but states that reviewing patient goals and pain should be whether the objective