Negative outcomes of unbalanced opioid policy supported by clinicians, politicians, and the media

A Case Report of Subanesthetic Ketamine Bolus and Infusion for Opioid Refractory Cancer Pain

Opioids and traditional adjuvant medications are frequently prescribed for the management of moderate to severe cancer pain with good effect. However, there are many cases, in which patients experience severe opioid refractory cancer pain. Ketamine is being used more frequently in the hospice and palliative setting to manage opioid refractory pain, although high-quality evidence regarding its effectiveness is lacking. It seems certain patients respond favorably to ketamine, while others experience no effect. Studies have not yet identified factors associated with a favorable response to ketamine. We present a case describing the successful treatment of high-dose opioid refractory cancer pain with a subanesthetic ketamine infusion and propose the novel use of a preinfusion test bolus of ketamine to identify patients who are likely to respond favorably to an infusion.

Addressing Bias and Stigma in the Language We Use With Persons With Opioid Use Disorder: A Narrative Review

BACKGROUND: Despite an increase in access to medications for opioid use disorder, less than 20% of individuals with opioid use disorder (OUD) receive treatment. Stigmatizing language has been identified as a potential trigger for explicit and implicit biases that may adversely affect treatment enrollment and quality of care for persons with OUD. AIMS: To conduct a narrative review of the literature on stigmatizing language and OUD, examine how treatment outcomes are affected, and present strategies to reduce bias and promote OUD treatment. METHOD: A narrative review of the literature between 2010 and 2019 was conducted using CINAHL, PubMed, and PsycINFO. Key search terms were opioid use disorder (or substance use disorder), stigma, and language. Fifty-two articles were screened for inclusion, and 17 articles were included in this review. RESULTS: The articles reviewed provide consensus that stigmatizing language toward persons with OUD fosters explicit and implicit bias and impedes engagement in treatment. Four themes emerged: (1) stigma and language, (2) stigma and language used by health care professionals, (3) stigma and language used by the general public, and (4) stigma and language used by people with OUD. CONCLUSIONS: Stigmatizing language is dehumanizing and plays a pivotal role in bias and discrimination that may contribute to unsatisfactory treatment outcomes among persons with OUD. Health care professionals, nursing in particular, must assume an intentional stance against stigma perpetuated toward persons with OUD through advocacy in education, practice, policy, and the media.

[Questionnaire made to understand the opioid analgesics prescription habits in the community of Madrid (Spain)]

OBJECTIVE

Pain is the fearest and disabling symptom for cancer patients. The cornerstone of treatment is opioid analgesics. The objective of this research was to relate the opioid consumption existing in the Community of Madrid (CM) with the prescription habits expressed by the Primary Care (PrC) and Palliative Care (PalC) physicians.

DESIGN

An opioid prescription habits questionnaire was designed. Sampling was consecutive non-probability. SITE: PrC and specific PalC resources in the CM.

PARTICIPANTS

The study population included all the family doctors who worked in PrC in the Madrid Public Health Service and all the physicians who worked in some specific PalC resources, both home-based teams and supportive hospital teams in the CM of the public and private/concerted health network services.

MAIN MEASUREMENTS

We asked about the strong and weak opioids most used in moderate-severe oncological and non-oncological pain, the preferred administration route, the safety in the use of opioids in the treatment of pain and the preferred clinical practice guidelines.

RESULTS

The questionnaire was answered by 840 PrC physicians (20%) and 56 PalC physicians (45%). For the treatment of moderate-severe cancer pain in both groups of professionals, the first choice was morphine; however, in non-cancer pain for PrC it was fentanyl and morphine for PalC professionals. Regarding the route of administration, 70% of family doctors and 87% of PalC physicians stated that the oral route was the first choice, compared to 27% in PrC and 5% in PalC who preferred the transdermal route. The PrC physicians rated their ability to use opioids as average (4-7/10), while the palliativists considered it as high (8-10/10). In PrC, they declared that they knew, above all, the European Association for Palliative Care (EAPC) and National Institute for Health and Care Excellence (NICE) guidelines, although the largest number answered that they trusted their experience. PalC physicians preferred to use the EAPC guide.

CONCLUSIONS

There is a clear disagreement between the actual consumption of opioids and the prescribing habits manifested by family doctors, as well as a false certainty in prescribing these drugs.

Is Europe also facing an opioid crisis?-A survey of European Pain Federation chapters

BACKGROUND

There is considerable public interest in whether Europe is facing an opioid crisis comparable to the one in the United States and the contribution of opioid prescriptions for pain to a potential opioid crisis.

METHODS

A task force of the European Pain Federation (EFIC) conducted a survey with its national chapter representatives on trends of opioid prescriptions and of drug-related emergency departments and substance use disorder treatment admissions and of deaths as proxies of opioid-related harms over the last 20 years.

RESULTS

Data from 25 European countries were received. In most European countries opioid prescriptions increased from 2004 to 2016. The levels of opioid consumption and their increase differed between countries. Some Eastern European countries still have a low opioid consumption. Opioids are mainly prescribed for acute pain and chronic noncancer pain in some Western and Northern European countries. There was a parallel increase in opioid prescriptions and some proxies of opioid-related harms in France, Finland and the Netherlands, but not in Germany, Spain and Norway. In United Kingdom, opioid overdose deaths, but not opioid prescriptions increased between 2016 and 2018. There are no robust data available on whether prescribed opioids for pain patients contributed to opioid-related harms.

CONCLUSIONS

There are marked differences between European countries in trends of opioid prescribing and of proxies for opioid-related harms. Europe as a whole is not facing an opioid crisis. Discussions on the potential harms of opioids should not obstruct their prescription for cancer pain and palliative care.

SIGNIFICANCE

Europe as a whole is not facing an opioid crisis. Some Eastern European countries have limited access to opioid medicines. Discussions on the potential harms of opioid medicines for noncancer pain should not obstruct opioid therapy for cancer therapy and palliative care.

Opioids: A 'crisis' of too much or not enough - or simply how rich you are and where you live?

The 'Opioid Crisis', which originated in Western countries, has been misrepresented and is misinforming the global public. For 20 years, since the advent of the synthetic opioids, 25,000 Americans, on average, have died annually from opioid-related overdoses. The United States produces and consumes by far the greatest amounts of opioids. National regulations introduced to curb overdoses and restrict opioid availability have condemned many Americans, such as cancer patients or those in need of palliative care, to a life of extreme pain due to lack of access to adequate pain management. As is often the case, US-driven laws have informed and guided international regulations. Worldwide, 83% of countries have low or non-existent access to opioids for pain relief. Over 25 million people are at the end-of-life stage, with eight million people dying annually in unnecessary pain and distress. Ineffectively controlled pain is a global public health issue blighting the lives of billions of people worldwide with immeasurable human and socioeconomic costs. International conventions regulate the trade and use of controlled medications, including many opioids. The goal is to balance widespread access to optimal forms of pain management with restrictions to govern the use and prevent the misuse of controlled substances. Those conventions are failing to meet their goals. International guidelines to inform national legislation have been compromised and withdrawn, thanks to undue interference from US-based opioid manufacturers. The new goal must be to ensure equitable access, for all, to opioids and ensure that optimal pain management becomes a central component of Universal Health Coverage. SIGNIFICANCE: The opioid crisis is, more accurately, a multicomponent global crisis and one that is not fully apparent or well understood. Regulations of the wealthy and powerful to control a surfeit of opioids, which encourages misuse, cannot be allowed to govern legislation in the majority of countries worldwide where citizens have little or no access to opioids to reduce pain and suffering. International conventions must be revised to ensure an optimal balance that allows access to opioids for all those who need them.

Risk of death associated with kratom use compared to opioids

Kratom use appears to be increasing across the United States, increasing attention to deaths in which kratom use was detected. Most such deaths have been ascribed to fentanyl, heroin, benzodiazepines, prescription opioids, cocaine and other causes (e.g., homicide, suicide and various preexisting diseases). Because kratom has certain opioid-like effects (e.g., pain relief), and is used by some people as a substitute for opioids for pain or addiction, kratom has been compared to "narcotic-like opioids" (e.g., morphine) with respect to risk of death despite evidence that its primary alkaloid, mitragynine, carries little of the signature respiratory depressing effects of morphine-like opioids. This commentary summarizes animal toxicology data, surveys and mortality data associated with opioids and kratom to provide a basis for estimating relative mortality risk. Population-level mortality estimates attributed to opioids as compared to kratom, and the per user mortality risks of opioids as compared to kratom are provided. By any of our assessments, it appears that the risk of overdose death is >1000 times greater for opioids than for kratom. The limitations of the mortality risk estimate warrants caution in individuals with unknown factors such as use of other substances and medications, or other preexisting conditions. More research on kratom safety and risks is needed, as is regulation of commercial kratom products to ensure that consumers are informed by FDA labeling and that kratom products are not contaminated or adulterated with other substances.

Mitigation of IV Abuse Through the Use of Abuse-Deterrent Opioid Formulations: An Overview of Current Technologies

Providers who treat patients with chronic pain face a dual challenge: providing adequate access to opioid therapies for appropriate pain management while adopting strategies to minimize the risk for abuse. Commonly prescribed opioids have substantial abuse potential when administered intravenously, and extended‐release (ER)/long‐acting (LA) opioids may be targeted for intravenous (IV) abuse because of the higher per‐dose medication level. The consequences of IV opioid abuse are severe and increase the risks for adverse outcomes, including mortality due to acute health events, serious infections, and deep vein thrombosis, to name a few. To reduce the potential for abuse of prescription opioids by both recreational and experienced drug abusers, abuse‐deterrent formulations (ADFs) of opioid medications employ either physical/chemical barriers or agonist‐antagonist combinations. Here we review the development and use of opioid ADFs as a harm‐reduction strategy, and their potential for mitigating IV opioid abuse. The approved ER/LA opioids with ADF labeling in the United States include formulations of oxycodone, hydrocodone, and morphine. Findings from in vitro laboratory tests of abuse deterrence for opioid ADFs are described herein, as are data from human abuse potential studies for IV abuse of those ADF products, for which such studies are feasible (ie, abuse‐deterrent agonist‐antagonist formulations). The available ADF opioids may decrease both the attractiveness and the feasibility of IV abuse. The adoption of ADF opioids represents one tactic for providing access to needed medication for patients with chronic pain, while potentially reducing the risk for opioid abuse, in a comprehensive effort to combat the opioid epidemic.

Quantifying the Adequacy of Opioid Analgesic Consumption Globally: An Updated Method and Early Findings

Opioid analgesics are the mainstay for treatment of moderate and severe pain but, in many countries, the consumption of these medicines is inadequate. Over time, various groups have published opioid analgesic metrics, including authors from the World Health Organization. They linked consumption to a level considered adequate based on the actual consumption in developed countries. In this study, we present our current results on the adequacy of opioid analgesic consumption. We included statistics for 18 controlled opioid medicines that are primarily used as analgesics, and we developed the Adequacy of Opioid Consumption (AOC) Index. The average of the 20 most developed countries for 2015 is set as equal to an AOC Index of 100. An AOC Index of 100 or higher is considered adequate consumption. The average opioid analgesic consumption of the top-20 countries of the Human Development Index increased from 84 morphine milligram equivalents per capita (2000) to 256 morphine milligram equivalents per capita (2015). The extremes we found for 2015 were Germany (AOC Index: 304) and Nigeria (AOC Index: 0.0069). These extremes differ by 44 000 times. Adequacy of opioid analgesic consumption continues to be problematic around the world.

Ensuring and Restoring Balance on Access to Controlled Substances for Medical and Scientific Purposes: Joint Statement from Palliative Care Organizations

The central principle of "balance" represents the dual obligation of governments to establish a system of control that ensures the adequate availability of controlled substances for medical and scientific purposes while simultaneously preventing their nonmedical use, diversion, and trafficking, two primary goals of the international control system. On the one hand, although strong opioids, including morphine, are absolutely necessary for the relief of severe pain, legitimate access to opioids for pain treatment and palliative care is lacking in the majority of the world's countries. On the other hand, in a few high-income countries with higher consumption of prescription opioids, diversion and nonmedical use are increasingly prevalent. This report presents examples of unbalanced systems and a joint statement from global and regional palliative care organizations to promote development of balanced systems for optimal public health outcomes. Although nonmedical use of controlled substances poses a risk to society, the system of control is not intended to be a barrier to their availability for medical and scientific purposes, nor to interfere in their legitimate medical use for patient care. As representatives of palliative care organizations, we urge heads of state to act and to take measures to ensure and restore balanced systems in their countries and call on public health leaders and regulators to work together.

International drug policy – health before politics

Purpose

The purpose of this paper is to explain how international drug policy continues to have a hugely damaging effect on population health, human rights and wellbeing, not only on individuals who consume and/or sell drugs but also on societies as a whole. And to review whether anything has changed after United Nations General Assembly Special Session.

Design/methodology/approach

UNGASS had been seen as a real opportunity for scientific evidence to become the driver of future drug policy. This paper looks at any changes that have since taken place that might support such an aspiration.

Findings

The authors found the criminalisation and incarceration of people who use drugs, mainly from the most marginalised sections of society, remains the primary response in almost every member state of the UN and there are at least 33 countries that retain the death penalty for drug offences. The impact on the health of people who inject drugs (PWIDs) living with HIV is devastating and overdose and AIDS related mortality are the leading causes of death. Hepatitis C infections among PWIDs are increasing at epidemic levels even though this now a curable disease.

Practical implications

Changes in drug policy urgently needed.

Originality/value

This paper is an important review of the health implications of bad drug policy.

Targeting practitioners: A review of guidelines, training, and policy in pain management

This paper reviews the current literature on clinical guidelines, practitioner training, and government/payer policies that have come forth in response to the national rise in prescription opioid overdoses. A review of clinical opioid prescribing guidelines highlights the need for more research on safe and effective treatment options for chronic pain, improved guidance for the best management of post-operative pain, and evaluation of the implementation and impact of guideline recommendations on patient risk and outcomes. Although there is increasing attention to training in pain management in medical schools and medical residency programs, educational opportunities remain highly variable, and the need for additional clinician training in the recognition and treatment of pain as well as opioid use disorder has been recognized. Mandated use of private, federal and state educational and clinical initiatives such as Risk Evaluation and Mitigation Strategies (REMS) and Prescription Drug Monitoring Programs (PDMPs) generally increase utilization of these initiatives, but more research is needed to determine the impact of these initiatives on provider behaviors, treatment access, and patient outcomes. Finally, there is an acute need for more research on safe and effective treatments for chronic pain as well as an increased multi-level focus on improving training and access to evidence-based treatment for opioid use disorder as well as non-pharmacologic and non-interventional chronic pain treatments, so that these guideline-recommended interventions can become mainstream, accessible, first-line interventions for chronic pain and/or opioid use disorders.

Evaluation of US Federal Legislation for Opioid Abuse: 1973-2016

The 114th Congress (2014-2016) has received recent attention for the high number of legislative bills directed to the public health crisis in prescription opioid abuse. The US government does not have a single source for determining public policy; however, the people expect that there will be some level of efficiency and coordination between federal and state leaders to improve the nation's health. A search of the National Library of Congress database to analyze legislative bills introduced between 1973 and 2016 and which contain the term "opioid" identified 127 bills that characterize consistency and coordination with other governmental efforts in prescription opioid abuse. Despite the recent number of introduced bills, there does not appear to be a close coordination between Congress and Federal Administrative agencies regarding this crisis.