Abuse of prescription of narcotics in primary care and its prevention - Dissertation Example

?The Review In the medical world, pain has consistently been categorized into two encompassing variations: firstly, the pain patients experience as aresult of malignant cancers; and secondly, chronic pain associated with non-malignant cancers, and other illnesses (Mangione & Crowley-Matoka, 2008). The prescription of opioids to assist the patients with malignant cancers has proven to be beneficial, but the increasing misuse and abuse of these medications by patients suffering from non-chronic pain has served to overshadow the benefits of opioids, despite the wide variety of medications available to treat non-cancer associated pain (Potter et al, 2001). While theoretically, the constant prescription of opioids is necessary and effective only in the treatment of malignant cancer-related, significantly more serious pain (Becker et al, 2011), health practitioners seem to have favored the prescription of these drugs in cases of all chronic pain (Potter et al, 2011). The supposition is therefore that this more widespread prescription has led to NUPM and PUPD. But it is not only the increase in prescription of opioids that can explain the ballooning of the incidence of NUPM. It seems that the failure of health professionals to monitor their patients’ use of drugs may also be a significant factor arguing for restraint, and even the cessation of the practice of widely prescribing opioids (Liebschutz et al, 2010). What are the conditions, consequently, that should accompany the distribution if opioids to patients? Is the only available, effective option to ban these medications outright, or would it be possible to formulate and implement policies that would effectively prevent abuse and misuse of these narcotics? A. Trends in the prescription of narcotics The findings of studies suggested that the varied barriers to the use of opioids must be addressed before any mandates or guidelines regulating the prescription of opioids can be implemented. Primary caregivers are more likely to be frustrated by the barriers, than by conforming to sets of guidelines. Therefore the prescription of opioids for the treatment of chronic pain in older patients is widespread. Spitz et al. (2011) found that the majority of the participants in their quantitative study were prescribing opioids to older patients, but only as a second or subsequent line of treatment. This initial reluctance may be due to the possibility of causing harm; the subjective nature of pain; deficient education regarding the effectiveness and consequences of using opioids; and the stigma attached to opioid use. Family members and the patients themselves were reluctant to try opioid treatment due to concerns regarding possible opioid abuse or misuse. In the findings of other studies, it was clear that significant attention had been given to the probability of substance abuse in patients prescribed opioids on a regular and ongoing basis. The clinical significance of the association between opioid use and common mental disorders is often overlooked. The evident lacunae resulting from the overemphasis on substance abuse, and the underemphasized incidence of mental disorders must be addressed. The prevalence of high-risk patients, in the prescription of opioid treatments, is a vital consideration. Patients on opioid treatment were found to be two to three times more likely to seek mental health assistance by Sullivan et al. (2006) despite their not reporting a higher requirement for substance abuse treatment. In this cross-sectional study, it was found that continued use of opioids in participants, over the period 1988-2001, posed an increased risk for common mental disorders. This study illustrates the link between common mental disorders, as well as substance abuse, with the continuous use of prescribed opioids based on evidence from a large prospective population based data study. Furthermore, a lack of confidence among physicians relating to the prescription of narcotics can be discerned. Nonetheless, urine toxicology screening was rarely carried out either prior to or after initiation of opioid treatment. Physicians were concerned with the use of opioids primarily due to possible abuse of opioids and addiction potential, and with the side effects of the treatment, the tolerance of individuals to the treatment, interaction with other medications, and poor knowledge of the use of narcotics. When primary physicians felt less confident or they had implemented systems to monitor patients, they were more likely to conduct screening tests. There is a high level of concern among primary physicians in prescribing opioids for the treatment of pain and a low level of confidence among them to use opioids. A cross-sectional quantitative study conducted in 2006 by Bhamb et al. revealed that the most frequently employed narcotics in primary care, used for the relief of chronic pain were: codeine, hydrocodone, oxycodone, morphine continuous release, and oxycodone extended release. The findings from studies such as these highlight the need to acknowledge that there is a marked lack of knowledge among primary care providers about the considerations necessary before prescription, and the possible consequences of prescription, in the management of pain. B. Education of primary caregivers in pain management When measuring the satisfaction of primary caregivers related to the effectiveness of treatments for pain, it was found that they experienced very low satisfaction when dealing with chronic pain. Most attending physicians reported that they considered the training they received during medical education and residencies was insufficient when it concerned the treatment of chronic pain. Again it was often reported that there was a low willingness to prescribe opioids – the reason for this primary barrier, cited in many papers, was fear that patients would sell their prescribed medicines. When patients were more regularly seen by the physicians, willingness to prescribe opioids increased. The education of primary caregivers needs to be more patient-focused, and include training on how to deal with substance abuse and addiction. Upshur et al.(2006) report that the data gained from their total perspective qualitative study showed that the barriers to optimal pain treatment were patient self-management, patient psychological factors, and patient compliance, in addition to the reluctance of physicians to prescribe opioids. The benefits of these drugs can be noted, however. Patients with pain and psychosocial problems, when pain was controlled, experienced enhanced physical ability, vitality and emotional functioning over six and twelve month periods. Training for primary caregivers in cognitive-behavioral approaches to chronic pain management improved the quality of the treatment offered by personnel. Ahles et al. (2006) conducted a randomized comparative cohort study to compare the effects on patients of effective pain management, and their findings argued for the improvement of patients’ quality of life due to prescription of opioids. The proposal that a nurse-educator approach should be used as a means to enhance the effectiveness of pain management in primary care was also derived from this study’s findings. Consequent to these findings, it is still evident that the choices of prescribing caregivers must be made from an informed basis. And this is where the prescription of opioids must be considered significant. The effectiveness of these drugs in treating the pain experienced by malignant cancer sufferers has already been noted in this paper, but what of the benefits or non-benefits to non-cancer chronic pain patients? C. Predictors and drawbacks of opioid use, misuse or abuse As noted previously, the link between opioid use and drug abuse, as well as the link between opioid use and mental disorder potential has been established. Significantly higher rates of any opioid misuse, problem opioid misuse, non-opioid illicit drug use, non-opioid problem drug use, and problem alcohol use was evident when users of prescribed opioids were compared to non-users. Nonetheless, some mediation of these results was able to be presumed – a proportion of subjects may have experienced depressive or anxiety disorders, influencing the frequency of opioid users’ likelihood to be wider abusers of substance. A study emphasizing these links was conducted by Edlund et al. in 2007, in which a cross sectional process produced unadjusted data illustrating the relationships mentioned above. Therefore, the necessity to balance the effective treatment of chronic pain with the very real potential of developing dependencies on opioids in patients, already reported on by many previous studies, is noted. But also a further element must be considered: the possibility that opioid users are at higher risk for more general drug dependency. Both the potential for non-opioid drug use, and the possibility of mental health disorders, prior to prescription of opioids, has to be part of the physician’s thinking. Furthermore, treatable mental health disorders may partially mediate the interaction between prescribed opioid drug use, and wider drug problems. It is thus clear that opioid use does have side effects that have to be acknowledged. The highest risk factor for developing dependence was a history of opioid abuse, but further risk factors included younger age, level of pain discomfort, higher severities of drug dependence, more frequent opioid disorders in EHR, and a history reflecting anti-social behavior. In a quantitative study carried out by Boscarino et al. (2010), 36% of participants in a survey met the criteria for life-long opioid dependence, and 26% the criteria for current dependence. This study did, however, have limitations in that data was obtained by patients’ self-reporting only. Additional shortcomings were the lack of optimal survey completion introducing the possibility of bias, and the racial composition of the participants: most were Caucasian, preventing the possibility of generalizing results to include other race groups. Nonetheless, the study did suggest certain possible actions for physicians prescribing opioids. In reviewing the literature in this area, a distinct necessity emerges: the monitoring, documentation and support of patients for whom opioids must be prescribed. Pre-screening seems to be an essential component. So too does an awareness of the potential risks associated with this medication. D. Monitoring, Documentation and Support A clear deficiency is apparent in documented guideline-recommended processes when opioids are considered. Guideline-recommended opioid management practices were not effectively implemented, generally, leading to poor monitoring of patients. Only when patients had recorded potential for opioid misuse was documentation and record-keeping thorough: of documentation used, reassessment for pain was most common while documentation recording an opioid treatment agreement was least used. Yet it has been shown that computer-aided systems enable simple, comparatively reliable and timely solutions and can assist in the access of information to enable effective decision-making for appropriate and effective pain treatment, as demonstrated in a comparative study by Wilsey et al. (2009).. Nonetheless, statistics recorded in a 2011 retrospective medical record study, conducted by Krebs et al. reveal that 57% of patients received prescriptions for long-acting opioids, as opposed to 72%, who received prescriptions for short-acting opioids. For only 33% of the patients considered in the study, the patients’ potential for opioid misuse was recorded in medical documentation. Thus far, the literature is pointing to the need for formal strategies to encompass both the inherent risks and inherent benefits of opioid treatment. The risks have been outlined above, in relative detail, and the necessity to improve the effectiveness of primary caregivers’ ability to treat chronic pain remains a focus. E. Consequences and mitigation strategies The need for long-term chronic opioid therapy cannot be denied. The prescription of antidepressants and antipsychotics in addition to opioids has been shown to offer improved protection. Individual aspects of the process of care have also been demonstrated as essential: if methadone was used as maintenance, individual mortality risk is influenced. But Methadone prescription could be better managed, with consideration of dosage, co-prescription and effective monitoring. Co-prescription of benzodiazepines, conversely, was shown to be extremely hazardous. In a retrospective cohort study, McCowan et al. (2009) demonstrated that longer duration of the use of methadone, elevated interval in filling of last methadone prescription, and history of urine testing were all able to offer protection in all-cause mortality. Further strategies have also been explored to maximize the effectiveness of pain management in primary care. Four major themes could be identified as possible ways to improve the management of CNMP in primary care. The first of these was the need for provider practice guidelines to regulate the use of opioids in the management of CNMP. Secondly, alterations to monthly opioid prescription process, and thirdly, self-management support and access to alternative management strategies for patients; finally the use of a nurse care manager would also be effective. Although not the main intention of a qualitative study conducted by Clark and Upshur in 2007, these suggestions allow for the improvement of the management of CNMP and should enable the limiting of misuse and abuse of opioids in primary care. The findings of this study could be extrapolated to imply that patients and providers would benefit from the adoption of models employed for other chronic illnesses. A number of changes need to be made, and that these changes will have an impact on clinical practice. While such interventions may be necessary, the implications are that clinical practitioners will have to adapt, and that is not always an easy process. F. Interventions and implications for clinical practice In a summative sense, findings in the literature suggest that for practitioners, a number of adaptations will be required. Better education in pain management and, simultaneously, in substance abuse was highlighted as necessary (Upshur, Kuckman & Savageau, 2006). Therefore, certain steps could be effective: a) An initial comprehensive assessment, to determine risk stratification as a starting point for all evaluations. Identification of risk factors – family history of addiction, personal history of emotional illness, even peer group pressure as a factor – to assist in preventing the prevention of misuse of narcotics (Edlund et al., 2007). b) Triaging patients according to addiction liability to de-feminize treatment strategies, and enable useful categorization of patients (Becker et al., 2007). The general public could be educated regarding the warning signs of potential abuse, preventative measures, and the inherent risks of prescription drugs. Patients could thus be informed, and hence make informed decisions about the positive or negative aspects of opioid therapy. Some options follow: a) The possibilities for non-opioid therapies should initially be explored, and their use maximized. Historically, such therapies have proven effective, and could be revisited for current cases. b) Alternative methods for the treatment of pain, to be used in conjunction with, or in lieu of, the medications prescribed could be explored with patients. A number of options present themseves: relaxation, mindfulness meditation, acceptance distraction, to name a few. Psychological interventions such as psychotherapy, stress management or biofeedback may be offered, as could physiotherapies. c) The side effects of opioid use must be discussed in detail between medical professional and patient. The patient must be aware that long-term use of opioids can lead to addiction, but also other effects revealed in the literature. d) Use of Opiate Treatment Agreements could be helpful in monitoring and managing appropriate use of opioids. Both the patient and the caregiver would be empowered by becoming signatories. Read More