Letters to the Editor: Naloxone, Opioid Tolerance, Polyarthropathy
I have been practicing pain management using medication protocols, interventional techniques, and pain relief surgical endeavors for almost 10 years in the academic and solo practice setting.
In the last 8 months, I have been happily surprised with the uptake and reception of my suggestion to my chronic pain patients that they keep in their home, an auto-injectable syringe of naloxone (Evzio). I describe it as the antidote to a suspected opioid overdose.
For the most part, the patients report that they sleep better at night knowing that this medication is accessible and “can save the day” before the paramedics arrive to deliver the same medication.
I insist that patients receive this medication (via my prescription) if they are on long-acting opioid medication, high doses of opioid medication, have a history of addiction or alcoholism, or have children in the home.
In my clinic, the patients listen to a presentation that myself or a team member delivers and then they have a chance to demonstrate their understanding by using the trainer device. The presentation includes signs of overdose, and the training is performed in a “crisis” role-play so that the patient feels comfortable if and when the time comes to use the medication.
Rajni Jutla, MD
We thank you for sharing your insightful experiences with naloxone. As a follow-up to your letter, we thought it apropos to take a step back and share our experiences with qualifying patients for in-home naloxone. Last July the American Medical Association (AMA) advocated for dual therapy of opioids and naloxone for all patients at risk that receive chronic opioid therapy.1
Dr. Fudin and I have worked extensively with risk mitigation when caring for patients on opioid therapies. Zedler et al developed the risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) score, a risk stratification tool that was originally validated in the veteran population to determine probability of an overdose of serious opioid-induced respiratory depression.2
Opioid dependence, psychiatric disorder, pulmonary disease, liver disease, use of an extended-release opioid, use of an antidepressant, use of a benzodiazepine, daily morphine equivalents per day, and recent hospitalization or emergency department visit were all identified as relevant factors that contribute to a patient’s opiate overdose risk.
The RIOSORD score is a 17-question survey with a total maximum score of 115. Each aforementioned variable contributes a certain percentage to the score and each RIOSORD score correlates with an average predicted probability of an opiate overdose or serious opioid-induced respiratory depression.
More recently, Zedler and colleagues validated a slightly revised RIOSORD in a retrospective case-control study in civilian patients consisting of approximately 18 million patients.3
Currently this score is being used in our clinics to determine which patients should be targeted for access to in-home naloxone. This report and use of the score help to streamline the process of identifying patients most in need and also hopefully help providers become more comfortable with prescribing this life-saving medication.
Our goal is to proactively identify patients who are at increased risk of an opioid-related overdose. Patients who generate a certain RIOSORD score of 25 or higher (correlating to a 14% risk of overdose or serious opioid-induced respiratory depression) are deemed appropriate to receive naloxone and commensurate training, which is generally completed by a pharmacist.
This strategy also affords a double check for dispensing pharmacists to foster dual therapy for naloxone in patients for whom it was not prescribed by the physician. The additional number of high risk patients with opioid dependence that are precluded from non-opioid therapy because of multiple medical comorbidities is astounding; this is a population of patients that requires further scrutiny.
An effort has recently ensued to educate off-site providers within communty-based outpatient clinic affiliates in rural locations. Our work could be broadened and further automated far beyond what we have achieved thus far. Currently our project is moving towards imbedding the RIOSORD score and associated percent risk into our electronic medical records system.
This effort is aimed to help all clinicians quickly and easily identify patients who are most at risk for an un-intentional opioid associated respiratory depression.
Editor's Note: The FDA approved an intranasal formulation of naloxone (Narcan) in November, 2015.
Jacqueline Pratt Cleary, PharmD.
Jeffrey Fudin, PharmD
Samuel Stratton, VA Medical Center
Albany, New York
Drs. Fudin and Cleary disclosed that their involvement with this article was not prepared as part of their official government duties.
Tolerance to Opioids
Practical Pain Management and Dr. Tennant, thank you for your article on Legacy Pain Patients, which detailed your clinical experience of patients safely consuming opioid medications for 30 years with stable dosing.4
Your clinical experience of absence of tolerance to opioid pain relieving properties is buttressed by 2-year studies,5,6 3-year studies,7-9 a 10-year study with “opioid dose escalation in only a few patients,”10 and your invaluable published study.
Some patients truly require a high-dose regimen that is commensurate with agonizing pathology, but fabrications of tolerance seems to have been a tool by which abusers achieved high dosing. Certainly over the past decade, too many clinicians prescribed opioids without proper study and patient pre-selection with monitoring, causing the predictable slingshot repercussions that all compassionate, careful, studious clinicians must now correct.
Pain management has regressed to an era where previously hard working, chronic pain patients are facing needless suffering from opioid phobia. In some cases, this has led to dangerous excessive consumption of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and ethanol, as well as functional regression and less contribution to society.
However, when viewed as an opportunity, that which doesn’t kill you makes you stronger.
The repercussions of the excessive prescribing era, hopefully, will result the creation of a nationwide Prescription Drug Monitoring Program. Such a program could help identify poor prescribers, who are averse to abuse-resistant opioid prescribing as well as the vast numbers of sub optimally trained prescribers.