Addiction management in the outpatient setting

Introduction

Since the 1990s, the increasing incidence of opioid use disorder (OUD) and overdose deaths involving opioids have reached epidemic proportions. Rising use has been associated with both medical and nonmedical opioid use. While opioids are an effective form of analgesia for acute and postoperative pain, the overprescribing of opioids, in part, has contributed to the escalation of opioid overdoses in the United States.

In 1996, the American Pain Society advocated for progressive evaluation of pain control with “the fifth vital sign” assessment. Although well intentioned and supported by physicians, patients, and professional societies, it promoted the aggressive treatment of both acute and chronic pain, often with opioids to improve subjective numeric pain scores at the point of care. During a similar time frame, opioid prescriptions rose dramatically, as did nonmedical opioid use. Individuals in the United States consumed more opioid medication than all other nations worldwide combined.

In 2013, the economic cost of prescription opioid-related overdose and OUD exceeded $78.5 billion with a large portion spent on healthcare, substance use disorder treatment, and loss of work productivity.

By 2017, opioid-related deaths continued to increase, and the United States government declared a public health emergency related to opioid use.

According to the 2019 National Survey on Drug Use and Health, 9.7 million people reported nonmedical use of prescription pain medicine. In an evidence-based consensus report published in 2019, an estimated 2.1 million people suffered from OUD, including 1.8 million with primary prescription opioid use and over 600,000 with primary heroin use.

In 2019, more than 70,000 Americans died from a drug-involved overdose, including illicit drugs and prescription opioids. Synthetic opioids, primarily fentanyl, were the main driver of these drug overdose deaths with a nearly 14-fold increase from 2012 to 2019 resulting in more than 36,359 casualties.

The Centers for Disease Control and Prevention (CDC) summarizes the rise in opioid overdose deaths in three distinct waves in its publication, “Understanding the Epidemic” ( Fig. 9.1 ).

• 1.

  The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids increasing since at least 1999.

• 2.

  The second wave began in 2010, with rapid increases in overdose deaths involving heroin.

• 3.

  The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl and its many analogs. Illicit fentanyl can be found in combination with heroin, counterfeit pills, and cocaine.

Many opioid-involved overdose deaths are associated with the use of multiple substances, including benzodiazepines, alcohol, cocaine, and methamphetamine.

There has been an ongoing public health crisis of infectious diseases driven by the opioid epidemic, including the transmission of the human immunodeficiency virus (HIV), hepatitis C, endocarditis, and infections of the skin, bones, and joints related to the rise of injection drug use. In addition to trauma and suicide risks, people with OUD have a 20-fold greater chance of early death.

What is opioid use disorder ?

OUD describes patients who have lost control and have a compulsion to use opioids. Physical dependence is the physical adaption to opioids characterized by symptoms of withdrawal when the drug is stopped and need to take more to get the desired effect. Physical dependence alone does not mean OUD. In fact, individuals who take opioids over a long enough period of time will develop physiologic dependence manifested by withdrawal and tolerance. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for OUD includes physical dependency, but differs as this is also characterized by the presence of cravings, compulsive use, and eventually loss of control, with continued use despite negative consequences from opioid use. Additionally, for patients prescribed opioids, physiologic dependence criteria should not be used in the diagnosis of OUD. The diagnostic criteria are summarized in Table 9.1 .

Risk of developing opioid use disorder

OUD is considered a bio-psycho-social illness. Genetic factors, psychological factors, and social environments can place an individual at a higher risk of developing OUD. See Table 9.2 . However, repeated opioid use alone can result in changes in neural structure and function and can change the brain's pleasure and reward pathways, leading to the development of OUD.

The likelihood of chronic opioid use after an opioid-naïve individual is prescribed an opioid medication has been shown to increase after as little as 3–5 days of opioid use.

In a survey of individuals who use heroin, approximately 75% reported nonmedical use of a prescription opioid in the prior year, often obtained from a family members' prescription or from opioid diversion from another individual's prescription.

A challenge that remains is the safe use of prescription opioids among surgical patients. More than 50 million Americans undergo inpatient surgery annually, and opioids remain a primary modality for postoperative acute pain management.

Surgical patients routinely receive the most commonly prescribed opioids—oxycodone and hydrocodone—which are also the most commonly implicated in nonmedical use and drug overdose deaths. ^, Consequently, it is of the utmost importance that all medical providers who prescribe opioid medications adopt screening and safe prescribing practices.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation's Clinical Practice Guideline on Opioid Prescribing for Analgesia After Common Otolaryngology Operations offers specialty-specific, evidence-based recommendations on the preoperative identification of OUD risk factors, and the postoperative management of pain, emphasizing prudent prescribing, storage, and disposal of opioids.

Screening for opioid use disorder

Every clinical encounter is an opportunity to screen for substance use disorder, and this is especially important when considering prescribing opioid medication for acute or postoperative pain.

The screening, brief intervention, and referral to treatment (SBIRT) model is a useful technique to identify patients at risk of substance use disorders. SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention for individuals with risky alcohol and drug use, as well as timely referral for treatment in those with substance use disorders. Primary care centers, hospital emergency rooms, trauma centers, and community health settings provide opportunities for early intervention before more consequences occur.

Safe prescribing practices

Pain following otolaryngological procedures can range from minimal to severe. Opioid prescriptions should be offered judiciously, with a high awareness for a preexisting OUD, and considerations for safe prescribing habits should be discussed to limit the potential for risk.

Patients who undergo otolaryngological procedures should be kept on limited opioids for postoperative pain control, or be treated with a nonopioid pain management modality if at all possible. Pain control and medication adherence should be assessed at appropriate postoperative follow-up.

Patients should be counseled on safe storage and disposal of opioid medications, as unused opioids can subsequently be diverted to nonmedical purposes by the patient, his or her family, or others who may have access to improperly stored medications. Studies have shown that the majority of patients kept their leftover pills in an unsecured location in their homes. Most patients were not given information on how to properly dispose of unused opioid medication. ^, CDC guidelines recommend disposing of unused opioids by dropping off medication at the community drug take-back program or your pharmacy mail-back program. Check with your local and state guidelines for any other options. ^,

Coprescribing naloxone with opioid medication is recommended to reduce the risk of opioid overdose. Naloxone comes in the following United States Food and Drug Administration (FDA)-approved forms: injectable, auto-injectable (Evzio), and prepackaged nasal spray. Instructions for administration should be reviewed with the patient and a household member, who may be assisting during the postoperative period.

Overview of opioid use disorder treatment

As with many chronic illnesses, treatment of OUD requires ongoing management and reduction of risks, rather than the attainment of a cure. Medication treatment of OUD is effective and enables people to counteract the disruptive effects on their brain and behavior and regain control of their lives. Table 9.3 describes the goals of medication management.

An understanding of opioid clinical pharmacology, especially the affinity for specific receptors and anticipated analgesic effects, is necessary for the selection of the appropriate opioid and nonopioid medication for pain management. ^, Different opioid classes have different pharmacologic effects on intrinsic opioid receptor activity with increasing doses. These classes are as follows: full opioid agonists, partial opioid agonists, and opioid antagonists ( Fig. 9.2 ).

• Full opioid agonists are substances that bind tightly to the opioid receptor and undergo a significant conformational change to produce a maximal effect. Examples of full opioid agonists include codeine, hydrocodone, oxycodone, morphine, methadone, fentanyl, and heroin.

• Partial opioid agonists are substances that cause less conformational change and receptor activation than full agonists. Examples of partial agonists include buprenorphine and pentazocine.

• Opioid antagonists are substances that block the effects of opioids by competitive binding to the opioid receptor. Examples of opioid antagonists include naloxone and naltrexone.

In 2018, the National Institute on Drug Abuse and the SAMSHA commissioned the National Academies of Sciences, Engineering, and Medicine (the National Academies) with developing a Consensus Study Report to update the current knowledge on medication-based treatment for OUD and to highlight gaps for future research, policy, and service provision.

A recent consensus report showed that medications are undeniably the most effective way to treat OUD, reducing the likelihood of overdose death by up to threefold. Combining opioid agonist medications with behavioral health counseling may offer the best treatment outcomes of OUD. ^, Effective agonist medication used for an indefinite period of time is the safest option for treating OUD.

Opioid detoxification programs without continued pharmacotherapy have not been shown to have long-term efficacy for treating OUD due to low rates of retention in treatment, high rates of relapse posttreatment, and increased rates of overdose due to decreased tolerance after a period of abstinence.