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FDA targets flavored cartridge-based e-cigarettes, but says it is not a ‘ban’
but states it is not a “ban.”
On Jan. 2, the agency issued enforcement guidance alerting companies that manufacture, distribute, and sell unauthorized flavored cartridge-based e-cigarettes within the next 30 days will risk FDA enforcement action.
FDA has had the authority to require premarket authorization of all e-cigarettes and other electronic nicotine delivery systems (ENDS) since August 2016, but thus far has exercised enforcement discretion regarding the need for premarket authorization for these types of products.
“By prioritizing enforcement against the products that are most widely used by children, our action today seeks to strike the right public health balance by maintaining e-cigarettes as a potential off-ramp for adults using combustible tobacco while ensuring these products don’t provide an on-ramp to nicotine addiction for our youth,” Department of Health & Human Services Secretary Alex Azar said in a statement.
The action comes in the wake of more than 2,500 vaping-related injuries being reported, including more than 50 deaths associated with vaping reported by the Centers for Disease Control and Prevention (although many are related to the use of tetrahydrocannabinol [THC] within vaping products) and a continued rise in youth use of e-cigarettes noted in government surveys.
The agency noted in a Jan. 2 statement announcing the enforcement action that, to date, no ENDS products have received a premarket authorization, “meaning that all ENDS products currently on the market are considered illegally marketed and are subject to enforcement, at any time, in the FDA’s discretion.”
FDA said it is prioritizing enforcement in 30 days against:
- Any flavored, cartridge-based ENDS product, other than those with a tobacco or menthol flavoring.
- All other ENDS products for which manufacturers are failing to take adequate measures to prevent access by minors.
- Any ENDS product that is targeted to minors or is likely to promote use by minors.
In the last category, this might include labeling or advertising resembling “kid-friendly food and drinks such as juice boxes or kid-friendly cereal; products marketed directly to minors by promoting ease of concealing the product or disguising it as another product; and products marketed with characters designed to appeal to youth,” according to the FDA statement.
As of May 12, FDA also will prioritize enforcement against any ENDS product for which the manufacturer has not submitted a premarket application. The agency will continue to exercise enforcement discretion for up to 1 year on these products if an application has been submitted, pending the review of that application.
“By not prioritizing enforcement against other flavored ENDS products in the same way as flavored cartridge-based ENDS products, the FDA has attempted to balance the public health concerns related to youth use of ENDS products with consideration regarding addicted adult cigarette smokers who may try to use ENDS products to transition away from combustible tobacco products,” the agency stated, adding that cartridge-based ENDS products are most commonly used among youth.
The FDA statement noted that the enforcement priorities outlined in the guidance document were not a “ban” on flavored or cartridge-based ENDS, noting the agency “has already accepted and begun review of several premarket applications for flavored ENDS products through the pathway that Congress established in the Tobacco Control Act. ... If a company can demonstrate to the FDA that a specific product meets the applicable standard set forth by Congress, including considering how the marketing of the product may affect youth initiation and use, then the FDA could authorize that product for sale.”
“Coupled with the recently signed legislation increasing the minimum age of sale of tobacco to 21, we believe this policy balances the urgency with which we must address the public health threat of youth use of e-cigarette products with the potential role that e-cigarettes may play in helping adult smokers transition completely away from combustible tobacco to a potentially less risky form of nicotine delivery,” FDA Commissioner Stephen Hahn, MD, said in a statement. “While we expect that responsible members of industry will comply with premarket requirements, we’re ready to take action against any unauthorized e-cigarette products as outlined in our priorities. We’ll also closely monitor the use rates of all e-cigarette products and take additional steps to address youth use as necessary.”
The American Medical Association criticized the action as not going far enough, even though it was a step in the right direction.
“The AMA is disappointed that menthol flavors, one of the most popular, will still be allowed, and that flavored e-liquids will remain on the market, leaving young people with easy access to alternative flavored e-cigarette products,” AMA President Patrice A. Harris, MD, said in a statement. “If we are serious about tackling this epidemic and keeping these harmful products out of the hands of young people, a total ban on all flavored e-cigarettes, in all forms and at all locations, is prudent and urgently needed. We are pleased the administration committed today to closely monitoring the situation and trends in e-cigarette use among young people, and to taking further action if needed.”
but states it is not a “ban.”
On Jan. 2, the agency issued enforcement guidance alerting companies that manufacture, distribute, and sell unauthorized flavored cartridge-based e-cigarettes within the next 30 days will risk FDA enforcement action.
FDA has had the authority to require premarket authorization of all e-cigarettes and other electronic nicotine delivery systems (ENDS) since August 2016, but thus far has exercised enforcement discretion regarding the need for premarket authorization for these types of products.
“By prioritizing enforcement against the products that are most widely used by children, our action today seeks to strike the right public health balance by maintaining e-cigarettes as a potential off-ramp for adults using combustible tobacco while ensuring these products don’t provide an on-ramp to nicotine addiction for our youth,” Department of Health & Human Services Secretary Alex Azar said in a statement.
The action comes in the wake of more than 2,500 vaping-related injuries being reported, including more than 50 deaths associated with vaping reported by the Centers for Disease Control and Prevention (although many are related to the use of tetrahydrocannabinol [THC] within vaping products) and a continued rise in youth use of e-cigarettes noted in government surveys.
The agency noted in a Jan. 2 statement announcing the enforcement action that, to date, no ENDS products have received a premarket authorization, “meaning that all ENDS products currently on the market are considered illegally marketed and are subject to enforcement, at any time, in the FDA’s discretion.”
FDA said it is prioritizing enforcement in 30 days against:
- Any flavored, cartridge-based ENDS product, other than those with a tobacco or menthol flavoring.
- All other ENDS products for which manufacturers are failing to take adequate measures to prevent access by minors.
- Any ENDS product that is targeted to minors or is likely to promote use by minors.
In the last category, this might include labeling or advertising resembling “kid-friendly food and drinks such as juice boxes or kid-friendly cereal; products marketed directly to minors by promoting ease of concealing the product or disguising it as another product; and products marketed with characters designed to appeal to youth,” according to the FDA statement.
As of May 12, FDA also will prioritize enforcement against any ENDS product for which the manufacturer has not submitted a premarket application. The agency will continue to exercise enforcement discretion for up to 1 year on these products if an application has been submitted, pending the review of that application.
“By not prioritizing enforcement against other flavored ENDS products in the same way as flavored cartridge-based ENDS products, the FDA has attempted to balance the public health concerns related to youth use of ENDS products with consideration regarding addicted adult cigarette smokers who may try to use ENDS products to transition away from combustible tobacco products,” the agency stated, adding that cartridge-based ENDS products are most commonly used among youth.
The FDA statement noted that the enforcement priorities outlined in the guidance document were not a “ban” on flavored or cartridge-based ENDS, noting the agency “has already accepted and begun review of several premarket applications for flavored ENDS products through the pathway that Congress established in the Tobacco Control Act. ... If a company can demonstrate to the FDA that a specific product meets the applicable standard set forth by Congress, including considering how the marketing of the product may affect youth initiation and use, then the FDA could authorize that product for sale.”
“Coupled with the recently signed legislation increasing the minimum age of sale of tobacco to 21, we believe this policy balances the urgency with which we must address the public health threat of youth use of e-cigarette products with the potential role that e-cigarettes may play in helping adult smokers transition completely away from combustible tobacco to a potentially less risky form of nicotine delivery,” FDA Commissioner Stephen Hahn, MD, said in a statement. “While we expect that responsible members of industry will comply with premarket requirements, we’re ready to take action against any unauthorized e-cigarette products as outlined in our priorities. We’ll also closely monitor the use rates of all e-cigarette products and take additional steps to address youth use as necessary.”
The American Medical Association criticized the action as not going far enough, even though it was a step in the right direction.
“The AMA is disappointed that menthol flavors, one of the most popular, will still be allowed, and that flavored e-liquids will remain on the market, leaving young people with easy access to alternative flavored e-cigarette products,” AMA President Patrice A. Harris, MD, said in a statement. “If we are serious about tackling this epidemic and keeping these harmful products out of the hands of young people, a total ban on all flavored e-cigarettes, in all forms and at all locations, is prudent and urgently needed. We are pleased the administration committed today to closely monitoring the situation and trends in e-cigarette use among young people, and to taking further action if needed.”
but states it is not a “ban.”
On Jan. 2, the agency issued enforcement guidance alerting companies that manufacture, distribute, and sell unauthorized flavored cartridge-based e-cigarettes within the next 30 days will risk FDA enforcement action.
FDA has had the authority to require premarket authorization of all e-cigarettes and other electronic nicotine delivery systems (ENDS) since August 2016, but thus far has exercised enforcement discretion regarding the need for premarket authorization for these types of products.
“By prioritizing enforcement against the products that are most widely used by children, our action today seeks to strike the right public health balance by maintaining e-cigarettes as a potential off-ramp for adults using combustible tobacco while ensuring these products don’t provide an on-ramp to nicotine addiction for our youth,” Department of Health & Human Services Secretary Alex Azar said in a statement.
The action comes in the wake of more than 2,500 vaping-related injuries being reported, including more than 50 deaths associated with vaping reported by the Centers for Disease Control and Prevention (although many are related to the use of tetrahydrocannabinol [THC] within vaping products) and a continued rise in youth use of e-cigarettes noted in government surveys.
The agency noted in a Jan. 2 statement announcing the enforcement action that, to date, no ENDS products have received a premarket authorization, “meaning that all ENDS products currently on the market are considered illegally marketed and are subject to enforcement, at any time, in the FDA’s discretion.”
FDA said it is prioritizing enforcement in 30 days against:
- Any flavored, cartridge-based ENDS product, other than those with a tobacco or menthol flavoring.
- All other ENDS products for which manufacturers are failing to take adequate measures to prevent access by minors.
- Any ENDS product that is targeted to minors or is likely to promote use by minors.
In the last category, this might include labeling or advertising resembling “kid-friendly food and drinks such as juice boxes or kid-friendly cereal; products marketed directly to minors by promoting ease of concealing the product or disguising it as another product; and products marketed with characters designed to appeal to youth,” according to the FDA statement.
As of May 12, FDA also will prioritize enforcement against any ENDS product for which the manufacturer has not submitted a premarket application. The agency will continue to exercise enforcement discretion for up to 1 year on these products if an application has been submitted, pending the review of that application.
“By not prioritizing enforcement against other flavored ENDS products in the same way as flavored cartridge-based ENDS products, the FDA has attempted to balance the public health concerns related to youth use of ENDS products with consideration regarding addicted adult cigarette smokers who may try to use ENDS products to transition away from combustible tobacco products,” the agency stated, adding that cartridge-based ENDS products are most commonly used among youth.
The FDA statement noted that the enforcement priorities outlined in the guidance document were not a “ban” on flavored or cartridge-based ENDS, noting the agency “has already accepted and begun review of several premarket applications for flavored ENDS products through the pathway that Congress established in the Tobacco Control Act. ... If a company can demonstrate to the FDA that a specific product meets the applicable standard set forth by Congress, including considering how the marketing of the product may affect youth initiation and use, then the FDA could authorize that product for sale.”
“Coupled with the recently signed legislation increasing the minimum age of sale of tobacco to 21, we believe this policy balances the urgency with which we must address the public health threat of youth use of e-cigarette products with the potential role that e-cigarettes may play in helping adult smokers transition completely away from combustible tobacco to a potentially less risky form of nicotine delivery,” FDA Commissioner Stephen Hahn, MD, said in a statement. “While we expect that responsible members of industry will comply with premarket requirements, we’re ready to take action against any unauthorized e-cigarette products as outlined in our priorities. We’ll also closely monitor the use rates of all e-cigarette products and take additional steps to address youth use as necessary.”
The American Medical Association criticized the action as not going far enough, even though it was a step in the right direction.
“The AMA is disappointed that menthol flavors, one of the most popular, will still be allowed, and that flavored e-liquids will remain on the market, leaving young people with easy access to alternative flavored e-cigarette products,” AMA President Patrice A. Harris, MD, said in a statement. “If we are serious about tackling this epidemic and keeping these harmful products out of the hands of young people, a total ban on all flavored e-cigarettes, in all forms and at all locations, is prudent and urgently needed. We are pleased the administration committed today to closely monitoring the situation and trends in e-cigarette use among young people, and to taking further action if needed.”
Lofexidine: An option for treating opioid withdrawal
Opioid use disorder (OUD) and deaths by opioid overdose are a major public health concern, especially with the advent of synthetic opioids such as fentanyl.1 Enrolling patients with OUD into substance abuse treatment programs can be a difficult hurdle to cross because patients do not want to experience withdrawal. The fear of withdrawal leads many individuals to refuse appropriate interventions. For these patients, consider the alpha-2 agonist lofexidine, which was FDA-approved in 2018 to help diminish the signs and symptoms of opioid withdrawal.1-3 Use of lofexidine might encourage more patients with OUD to accept substance abuse treatment.1,4,5
How to prescribe lofexidine
For decades, clinicians in Britain have prescribed lofexidine to attenuate opioid withdrawal.1An analog of clonidine, lofexidine is reportedly less likely than clonidine to induce hypotension.1,4 While this agent does not diminish drug toxicity, it can provide symptomatic relief for patients undergoing opioid withdrawal, and is efficacious as a supplement to and/or replacement for methadone, buprenorphine, clonidine, or other symptomatic pharmacotherapies.1,4,5
Lofexidine is available in 0.18-mg tablets. For patients experiencing overt symptoms of opioid withdrawal, initially prescribe 3 0.18-mg tablets, 4 times a day.3 The recommended maximum dosage is 2.88 mg/d, and each dose generally should not exceed 0.72 mg/d. Lofexidine may be continued for up to 14 days, with dosing guided by symptoms. Initiate a taper once the patient no longer experiences withdrawal symptoms.3
Adverse effects. Lofexidine’s efficacy and safety were evaluated in 3 randomized, double-blind, placebo-controlled trials that included 935 participants dependent on short-acting opioids who were experiencing abrupt opioid withdrawal and received lofexidine, 2.16 or 2.88 mg/d, or placebo.3 The most common adverse effects of lofexidine were insomnia, orthostatic hypotension, bradycardia, hypotension, dizziness, somnolence, sedation, and dry mouth.3 In the 3 trials, these effects were reported by ≥10% of patients receiving lofexidine, and occurred more frequently compared with placebo (Table3).
Take precautions when prescribing lofexidine because it can cause QT prolongation and CNS depression, especially when co-administered with sedative agents.3 It also can result in rebound hypertension once discontinued. This may be minimized by gradually reducing the dosage.3
A pathway to OUD treatment
Lofexidine can help relieve symptoms of opioid withdrawal, such as stomach cramps, muscle spasms or twitching, feeling cold, muscular tension, and aches and pains.1-5 This new option might help clinicians encourage more patients with OUD to fully engage in substance abuse treatment.
1. Rehman SU, Maqsood MH, Bajwa H, et al. Clinical efficacy and safety profile of lofexidine hydrochloride in treating opioid withdrawal symptoms: a review of literature. Cureus. 2019;11(6):e4827. doi: 10.7759/cureus.4827.
2. FDA approves the first non-opioid treatment for management of opioid withdrawal symptoms in adults. US Food & Drug Administration. https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm607884.htm. Published May 16, 2018. Accessed December 13, 2019.
3. Lucemyra [package insert]. Louisville, KY: US WorldMeds, LLC; 2018.
4. Carnwath T, Hardman J. Randomized double-blind comparison of lofexidine and clonidine in the out-patient treatment of opiate withdrawal. Drug Alcohol Depend. 1998;50(3):251-254.
5. Gonzalez G, Oliveto A, Kosten TR. Combating opiate dependence: a comparison among the available pharmacological options. Exp Opin Pharmacother. 2004;5(4):713-725.
Opioid use disorder (OUD) and deaths by opioid overdose are a major public health concern, especially with the advent of synthetic opioids such as fentanyl.1 Enrolling patients with OUD into substance abuse treatment programs can be a difficult hurdle to cross because patients do not want to experience withdrawal. The fear of withdrawal leads many individuals to refuse appropriate interventions. For these patients, consider the alpha-2 agonist lofexidine, which was FDA-approved in 2018 to help diminish the signs and symptoms of opioid withdrawal.1-3 Use of lofexidine might encourage more patients with OUD to accept substance abuse treatment.1,4,5
How to prescribe lofexidine
For decades, clinicians in Britain have prescribed lofexidine to attenuate opioid withdrawal.1An analog of clonidine, lofexidine is reportedly less likely than clonidine to induce hypotension.1,4 While this agent does not diminish drug toxicity, it can provide symptomatic relief for patients undergoing opioid withdrawal, and is efficacious as a supplement to and/or replacement for methadone, buprenorphine, clonidine, or other symptomatic pharmacotherapies.1,4,5
Lofexidine is available in 0.18-mg tablets. For patients experiencing overt symptoms of opioid withdrawal, initially prescribe 3 0.18-mg tablets, 4 times a day.3 The recommended maximum dosage is 2.88 mg/d, and each dose generally should not exceed 0.72 mg/d. Lofexidine may be continued for up to 14 days, with dosing guided by symptoms. Initiate a taper once the patient no longer experiences withdrawal symptoms.3
Adverse effects. Lofexidine’s efficacy and safety were evaluated in 3 randomized, double-blind, placebo-controlled trials that included 935 participants dependent on short-acting opioids who were experiencing abrupt opioid withdrawal and received lofexidine, 2.16 or 2.88 mg/d, or placebo.3 The most common adverse effects of lofexidine were insomnia, orthostatic hypotension, bradycardia, hypotension, dizziness, somnolence, sedation, and dry mouth.3 In the 3 trials, these effects were reported by ≥10% of patients receiving lofexidine, and occurred more frequently compared with placebo (Table3).
Take precautions when prescribing lofexidine because it can cause QT prolongation and CNS depression, especially when co-administered with sedative agents.3 It also can result in rebound hypertension once discontinued. This may be minimized by gradually reducing the dosage.3
A pathway to OUD treatment
Lofexidine can help relieve symptoms of opioid withdrawal, such as stomach cramps, muscle spasms or twitching, feeling cold, muscular tension, and aches and pains.1-5 This new option might help clinicians encourage more patients with OUD to fully engage in substance abuse treatment.
Opioid use disorder (OUD) and deaths by opioid overdose are a major public health concern, especially with the advent of synthetic opioids such as fentanyl.1 Enrolling patients with OUD into substance abuse treatment programs can be a difficult hurdle to cross because patients do not want to experience withdrawal. The fear of withdrawal leads many individuals to refuse appropriate interventions. For these patients, consider the alpha-2 agonist lofexidine, which was FDA-approved in 2018 to help diminish the signs and symptoms of opioid withdrawal.1-3 Use of lofexidine might encourage more patients with OUD to accept substance abuse treatment.1,4,5
How to prescribe lofexidine
For decades, clinicians in Britain have prescribed lofexidine to attenuate opioid withdrawal.1An analog of clonidine, lofexidine is reportedly less likely than clonidine to induce hypotension.1,4 While this agent does not diminish drug toxicity, it can provide symptomatic relief for patients undergoing opioid withdrawal, and is efficacious as a supplement to and/or replacement for methadone, buprenorphine, clonidine, or other symptomatic pharmacotherapies.1,4,5
Lofexidine is available in 0.18-mg tablets. For patients experiencing overt symptoms of opioid withdrawal, initially prescribe 3 0.18-mg tablets, 4 times a day.3 The recommended maximum dosage is 2.88 mg/d, and each dose generally should not exceed 0.72 mg/d. Lofexidine may be continued for up to 14 days, with dosing guided by symptoms. Initiate a taper once the patient no longer experiences withdrawal symptoms.3
Adverse effects. Lofexidine’s efficacy and safety were evaluated in 3 randomized, double-blind, placebo-controlled trials that included 935 participants dependent on short-acting opioids who were experiencing abrupt opioid withdrawal and received lofexidine, 2.16 or 2.88 mg/d, or placebo.3 The most common adverse effects of lofexidine were insomnia, orthostatic hypotension, bradycardia, hypotension, dizziness, somnolence, sedation, and dry mouth.3 In the 3 trials, these effects were reported by ≥10% of patients receiving lofexidine, and occurred more frequently compared with placebo (Table3).
Take precautions when prescribing lofexidine because it can cause QT prolongation and CNS depression, especially when co-administered with sedative agents.3 It also can result in rebound hypertension once discontinued. This may be minimized by gradually reducing the dosage.3
A pathway to OUD treatment
Lofexidine can help relieve symptoms of opioid withdrawal, such as stomach cramps, muscle spasms or twitching, feeling cold, muscular tension, and aches and pains.1-5 This new option might help clinicians encourage more patients with OUD to fully engage in substance abuse treatment.
1. Rehman SU, Maqsood MH, Bajwa H, et al. Clinical efficacy and safety profile of lofexidine hydrochloride in treating opioid withdrawal symptoms: a review of literature. Cureus. 2019;11(6):e4827. doi: 10.7759/cureus.4827.
2. FDA approves the first non-opioid treatment for management of opioid withdrawal symptoms in adults. US Food & Drug Administration. https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm607884.htm. Published May 16, 2018. Accessed December 13, 2019.
3. Lucemyra [package insert]. Louisville, KY: US WorldMeds, LLC; 2018.
4. Carnwath T, Hardman J. Randomized double-blind comparison of lofexidine and clonidine in the out-patient treatment of opiate withdrawal. Drug Alcohol Depend. 1998;50(3):251-254.
5. Gonzalez G, Oliveto A, Kosten TR. Combating opiate dependence: a comparison among the available pharmacological options. Exp Opin Pharmacother. 2004;5(4):713-725.
1. Rehman SU, Maqsood MH, Bajwa H, et al. Clinical efficacy and safety profile of lofexidine hydrochloride in treating opioid withdrawal symptoms: a review of literature. Cureus. 2019;11(6):e4827. doi: 10.7759/cureus.4827.
2. FDA approves the first non-opioid treatment for management of opioid withdrawal symptoms in adults. US Food & Drug Administration. https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm607884.htm. Published May 16, 2018. Accessed December 13, 2019.
3. Lucemyra [package insert]. Louisville, KY: US WorldMeds, LLC; 2018.
4. Carnwath T, Hardman J. Randomized double-blind comparison of lofexidine and clonidine in the out-patient treatment of opiate withdrawal. Drug Alcohol Depend. 1998;50(3):251-254.
5. Gonzalez G, Oliveto A, Kosten TR. Combating opiate dependence: a comparison among the available pharmacological options. Exp Opin Pharmacother. 2004;5(4):713-725.
Dual e-cigarette and combustible tobacco use compound respiratory disease risk
according to recent longitudinal analysis published in the American Journal of Preventive Medicine.
E-cigarettes have been promoted as a safer alternative to combustible tobacco, and until recently, there has been little and conflicting evidence by which to test this hypothesis. This study conducted by Dharma N. Bhatta, PhD, and Stanton A. Glantz, PhD, of the Center for Tobacco Control Research and Education at the University of California, San Francisco, is one of the first longitudinal examinations of e-cigarette use and controlling for combustible tobacco use.
Dr. Bhatta and Dr. Glantz performed a multivariable, logistic regression analysis of adults enrolled in the nationally representative, population-based, longitudinal Population Assessment of Tobacco and Health study. The researchers analyzed the tobacco use of adults in the study in three waves, following them through wave 1 (September 2013 to December 2014), wave 2 (October 2014 to October 2015), and wave 3 (October 2015 to October 2016), analyzing the data between 2018 and 2019. Overall, wave 1 began with 32,320 participants, and 15.1% of adults reported respiratory disease at baseline.
Lung or respiratory disease was assessed by asking participants whether they had been told by a health professional that they had chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or asthma. The researchers defined e-cigarette and combustible tobacco use as participants who never, currently, or formerly used e-cigarettes or smoked combustible tobacco. Participants who indicated they used e-cigarettes or combustible tobacco frequently or infrequently were placed in the current-user group, while past users were those participants who said they used to, but no longer use e-cigarettes or combustible tobacco.
The results showed former e-cigarette use (adjusted odds ratio, 1.34; 95% confidence interval, 1.23-1.46) and current e-cigarette use (aOR, 1.32; 95% CI, 1.17-1.49) were associated with an increased risk of having incident respiratory disease.
The data showed a not unexpected statistically significant association between former combustible tobacco use (aOR, 1.29; 95% CI, 1.14-1.47) as well as current combustible tobacco use (aOR, 1.61; 95% CI, 1.42-1.82) and incident respiratory disease risk.
There was a statistically significant association between respiratory disease and former or current e-cigarette use for adults who did not have respiratory disease at baseline, after adjusting for factors such as current combustible tobacco use, clinical variables, and demographic differences. Participants in wave 1 who reported former (aOR, 1.31; 95% CI, 1.07-1.60) or current e-cigarette use (aOR, 1.29; 95% CI, 1.03-1.61) had a significantly higher risk of developing incident respiratory disease in subsequent waves. There was also a statistically significant association between use of combustible tobacco and subsequent respiratory disease in later waves of the study (aOR, 2.56; 95% CI, 1.92-3.41), which the researchers noted was independent of the usual risks associated with combustible tobacco.
The investigators also looked at the link between dual use of e-cigarettes and combustible tobacco and respiratory disease risk. “The much more common pattern is dual use, in which an e-cigarette user continues to smoke combusted tobacco products at the same time (93.7% of e-cigarette users at wave 2 and 91.2% at wave 3 also used combustible tobacco; 73.3% of e-cigarette users at wave 2 and 64.9% at wave 3 also smoked cigarettes),” they wrote.
The odds of developing respiratory disease for participants who used both e-cigarettes and combustible tobacco were 3.30, compared with a participant who never used e-cigarettes, with similar results seen when comparing e-cigarettes and cigarettes.
“Although switching from combustible tobacco, including cigarettes, to e-cigarettes theoretically could reduce the risk of developing respiratory disease, current evidence indicates a high prevalence of dual use, which is associated with in-creased risk beyond combustible tobacco use,” the investigators wrote.
Harold J. Farber, MD, FCCP, professor of pediatrics in the pulmonary section at Baylor College of Medicine and Texas Children’s Hospital, both in Houston, said in an interview that the increased respiratory risk among dual users, who are likely using e-cigarettes and combustible tobacco together as a way to quit smoking, is particularly concerning.
“There is substantial reason to be concerned about efficacy of electronic cigarette products. Real-world observational studies have shown that, on average, tobacco smokers who use electronic cigarettes are less likely to stop smoking than those who do not use electronic cigarettes,” he said. “People who have stopped tobacco smoking but use electronic cigarettes are more likely to relapse to tobacco smoking than those who do not use electronic cigarettes.”
Dr. Farber noted that there are other Food and Drug Administration–approved medications for treating tobacco addiction. In addition, the World Health Organization, American Medical Association, Centers for Disease Control and Prevention, and FDA have all advised that e-cigarettes should not be used as smoking cessation aids, he said, especially in light of current outbreak of life-threatening e-cigarette and vaping lung injuries currently being investigated by the CDC and FDA.
“These study results suggest that the CDC reports of e-cigarette, or vaping, product use–associated lung injury are likely to be just the tip of the iceberg,” he said. “Although the CDC has identified vitamin E acetate–containing products as an important culprit, it is unlikely to be the only one. There are many substances in the emissions of e-cigarettes that have known irritant and/or toxic effects on the airways.”
Dr. Bhatta and Dr. Glantz acknowledged several limitations in their analysis, including the possibility of recall bias, not distinguishing between nondaily and daily e-cigarette or combustible tobacco use, and combining respiratory conditions together to achieve adequate power. The study shows an association, but the mechanism by which e-cigarettes may contribute to the development of lung disease remains under investigation.
This study was supported by grants from the National Institute on Drug Abuse; the National Cancer Institute; the FDA Center for Tobacco Products; the National Heart, Lung, and Blood Institute; and the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center Global Cancer Program. Dr. Bhatta and Dr. Glantz reported no relevant conflicts of interest.
SOURCE: Bhatta DN, Glantz SA. Am J Prev Med. 2019 Dec 16. doi: 10.1016/j.amepre.2019.07.028.
according to recent longitudinal analysis published in the American Journal of Preventive Medicine.
E-cigarettes have been promoted as a safer alternative to combustible tobacco, and until recently, there has been little and conflicting evidence by which to test this hypothesis. This study conducted by Dharma N. Bhatta, PhD, and Stanton A. Glantz, PhD, of the Center for Tobacco Control Research and Education at the University of California, San Francisco, is one of the first longitudinal examinations of e-cigarette use and controlling for combustible tobacco use.
Dr. Bhatta and Dr. Glantz performed a multivariable, logistic regression analysis of adults enrolled in the nationally representative, population-based, longitudinal Population Assessment of Tobacco and Health study. The researchers analyzed the tobacco use of adults in the study in three waves, following them through wave 1 (September 2013 to December 2014), wave 2 (October 2014 to October 2015), and wave 3 (October 2015 to October 2016), analyzing the data between 2018 and 2019. Overall, wave 1 began with 32,320 participants, and 15.1% of adults reported respiratory disease at baseline.
Lung or respiratory disease was assessed by asking participants whether they had been told by a health professional that they had chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or asthma. The researchers defined e-cigarette and combustible tobacco use as participants who never, currently, or formerly used e-cigarettes or smoked combustible tobacco. Participants who indicated they used e-cigarettes or combustible tobacco frequently or infrequently were placed in the current-user group, while past users were those participants who said they used to, but no longer use e-cigarettes or combustible tobacco.
The results showed former e-cigarette use (adjusted odds ratio, 1.34; 95% confidence interval, 1.23-1.46) and current e-cigarette use (aOR, 1.32; 95% CI, 1.17-1.49) were associated with an increased risk of having incident respiratory disease.
The data showed a not unexpected statistically significant association between former combustible tobacco use (aOR, 1.29; 95% CI, 1.14-1.47) as well as current combustible tobacco use (aOR, 1.61; 95% CI, 1.42-1.82) and incident respiratory disease risk.
There was a statistically significant association between respiratory disease and former or current e-cigarette use for adults who did not have respiratory disease at baseline, after adjusting for factors such as current combustible tobacco use, clinical variables, and demographic differences. Participants in wave 1 who reported former (aOR, 1.31; 95% CI, 1.07-1.60) or current e-cigarette use (aOR, 1.29; 95% CI, 1.03-1.61) had a significantly higher risk of developing incident respiratory disease in subsequent waves. There was also a statistically significant association between use of combustible tobacco and subsequent respiratory disease in later waves of the study (aOR, 2.56; 95% CI, 1.92-3.41), which the researchers noted was independent of the usual risks associated with combustible tobacco.
The investigators also looked at the link between dual use of e-cigarettes and combustible tobacco and respiratory disease risk. “The much more common pattern is dual use, in which an e-cigarette user continues to smoke combusted tobacco products at the same time (93.7% of e-cigarette users at wave 2 and 91.2% at wave 3 also used combustible tobacco; 73.3% of e-cigarette users at wave 2 and 64.9% at wave 3 also smoked cigarettes),” they wrote.
The odds of developing respiratory disease for participants who used both e-cigarettes and combustible tobacco were 3.30, compared with a participant who never used e-cigarettes, with similar results seen when comparing e-cigarettes and cigarettes.
“Although switching from combustible tobacco, including cigarettes, to e-cigarettes theoretically could reduce the risk of developing respiratory disease, current evidence indicates a high prevalence of dual use, which is associated with in-creased risk beyond combustible tobacco use,” the investigators wrote.
Harold J. Farber, MD, FCCP, professor of pediatrics in the pulmonary section at Baylor College of Medicine and Texas Children’s Hospital, both in Houston, said in an interview that the increased respiratory risk among dual users, who are likely using e-cigarettes and combustible tobacco together as a way to quit smoking, is particularly concerning.
“There is substantial reason to be concerned about efficacy of electronic cigarette products. Real-world observational studies have shown that, on average, tobacco smokers who use electronic cigarettes are less likely to stop smoking than those who do not use electronic cigarettes,” he said. “People who have stopped tobacco smoking but use electronic cigarettes are more likely to relapse to tobacco smoking than those who do not use electronic cigarettes.”
Dr. Farber noted that there are other Food and Drug Administration–approved medications for treating tobacco addiction. In addition, the World Health Organization, American Medical Association, Centers for Disease Control and Prevention, and FDA have all advised that e-cigarettes should not be used as smoking cessation aids, he said, especially in light of current outbreak of life-threatening e-cigarette and vaping lung injuries currently being investigated by the CDC and FDA.
“These study results suggest that the CDC reports of e-cigarette, or vaping, product use–associated lung injury are likely to be just the tip of the iceberg,” he said. “Although the CDC has identified vitamin E acetate–containing products as an important culprit, it is unlikely to be the only one. There are many substances in the emissions of e-cigarettes that have known irritant and/or toxic effects on the airways.”
Dr. Bhatta and Dr. Glantz acknowledged several limitations in their analysis, including the possibility of recall bias, not distinguishing between nondaily and daily e-cigarette or combustible tobacco use, and combining respiratory conditions together to achieve adequate power. The study shows an association, but the mechanism by which e-cigarettes may contribute to the development of lung disease remains under investigation.
This study was supported by grants from the National Institute on Drug Abuse; the National Cancer Institute; the FDA Center for Tobacco Products; the National Heart, Lung, and Blood Institute; and the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center Global Cancer Program. Dr. Bhatta and Dr. Glantz reported no relevant conflicts of interest.
SOURCE: Bhatta DN, Glantz SA. Am J Prev Med. 2019 Dec 16. doi: 10.1016/j.amepre.2019.07.028.
according to recent longitudinal analysis published in the American Journal of Preventive Medicine.
E-cigarettes have been promoted as a safer alternative to combustible tobacco, and until recently, there has been little and conflicting evidence by which to test this hypothesis. This study conducted by Dharma N. Bhatta, PhD, and Stanton A. Glantz, PhD, of the Center for Tobacco Control Research and Education at the University of California, San Francisco, is one of the first longitudinal examinations of e-cigarette use and controlling for combustible tobacco use.
Dr. Bhatta and Dr. Glantz performed a multivariable, logistic regression analysis of adults enrolled in the nationally representative, population-based, longitudinal Population Assessment of Tobacco and Health study. The researchers analyzed the tobacco use of adults in the study in three waves, following them through wave 1 (September 2013 to December 2014), wave 2 (October 2014 to October 2015), and wave 3 (October 2015 to October 2016), analyzing the data between 2018 and 2019. Overall, wave 1 began with 32,320 participants, and 15.1% of adults reported respiratory disease at baseline.
Lung or respiratory disease was assessed by asking participants whether they had been told by a health professional that they had chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or asthma. The researchers defined e-cigarette and combustible tobacco use as participants who never, currently, or formerly used e-cigarettes or smoked combustible tobacco. Participants who indicated they used e-cigarettes or combustible tobacco frequently or infrequently were placed in the current-user group, while past users were those participants who said they used to, but no longer use e-cigarettes or combustible tobacco.
The results showed former e-cigarette use (adjusted odds ratio, 1.34; 95% confidence interval, 1.23-1.46) and current e-cigarette use (aOR, 1.32; 95% CI, 1.17-1.49) were associated with an increased risk of having incident respiratory disease.
The data showed a not unexpected statistically significant association between former combustible tobacco use (aOR, 1.29; 95% CI, 1.14-1.47) as well as current combustible tobacco use (aOR, 1.61; 95% CI, 1.42-1.82) and incident respiratory disease risk.
There was a statistically significant association between respiratory disease and former or current e-cigarette use for adults who did not have respiratory disease at baseline, after adjusting for factors such as current combustible tobacco use, clinical variables, and demographic differences. Participants in wave 1 who reported former (aOR, 1.31; 95% CI, 1.07-1.60) or current e-cigarette use (aOR, 1.29; 95% CI, 1.03-1.61) had a significantly higher risk of developing incident respiratory disease in subsequent waves. There was also a statistically significant association between use of combustible tobacco and subsequent respiratory disease in later waves of the study (aOR, 2.56; 95% CI, 1.92-3.41), which the researchers noted was independent of the usual risks associated with combustible tobacco.
The investigators also looked at the link between dual use of e-cigarettes and combustible tobacco and respiratory disease risk. “The much more common pattern is dual use, in which an e-cigarette user continues to smoke combusted tobacco products at the same time (93.7% of e-cigarette users at wave 2 and 91.2% at wave 3 also used combustible tobacco; 73.3% of e-cigarette users at wave 2 and 64.9% at wave 3 also smoked cigarettes),” they wrote.
The odds of developing respiratory disease for participants who used both e-cigarettes and combustible tobacco were 3.30, compared with a participant who never used e-cigarettes, with similar results seen when comparing e-cigarettes and cigarettes.
“Although switching from combustible tobacco, including cigarettes, to e-cigarettes theoretically could reduce the risk of developing respiratory disease, current evidence indicates a high prevalence of dual use, which is associated with in-creased risk beyond combustible tobacco use,” the investigators wrote.
Harold J. Farber, MD, FCCP, professor of pediatrics in the pulmonary section at Baylor College of Medicine and Texas Children’s Hospital, both in Houston, said in an interview that the increased respiratory risk among dual users, who are likely using e-cigarettes and combustible tobacco together as a way to quit smoking, is particularly concerning.
“There is substantial reason to be concerned about efficacy of electronic cigarette products. Real-world observational studies have shown that, on average, tobacco smokers who use electronic cigarettes are less likely to stop smoking than those who do not use electronic cigarettes,” he said. “People who have stopped tobacco smoking but use electronic cigarettes are more likely to relapse to tobacco smoking than those who do not use electronic cigarettes.”
Dr. Farber noted that there are other Food and Drug Administration–approved medications for treating tobacco addiction. In addition, the World Health Organization, American Medical Association, Centers for Disease Control and Prevention, and FDA have all advised that e-cigarettes should not be used as smoking cessation aids, he said, especially in light of current outbreak of life-threatening e-cigarette and vaping lung injuries currently being investigated by the CDC and FDA.
“These study results suggest that the CDC reports of e-cigarette, or vaping, product use–associated lung injury are likely to be just the tip of the iceberg,” he said. “Although the CDC has identified vitamin E acetate–containing products as an important culprit, it is unlikely to be the only one. There are many substances in the emissions of e-cigarettes that have known irritant and/or toxic effects on the airways.”
Dr. Bhatta and Dr. Glantz acknowledged several limitations in their analysis, including the possibility of recall bias, not distinguishing between nondaily and daily e-cigarette or combustible tobacco use, and combining respiratory conditions together to achieve adequate power. The study shows an association, but the mechanism by which e-cigarettes may contribute to the development of lung disease remains under investigation.
This study was supported by grants from the National Institute on Drug Abuse; the National Cancer Institute; the FDA Center for Tobacco Products; the National Heart, Lung, and Blood Institute; and the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center Global Cancer Program. Dr. Bhatta and Dr. Glantz reported no relevant conflicts of interest.
SOURCE: Bhatta DN, Glantz SA. Am J Prev Med. 2019 Dec 16. doi: 10.1016/j.amepre.2019.07.028.
FROM THE AMERICAN JOURNAL OF PREVENTIVE MEDICINE
Vaping marijuana gaining traction among U.S. teens
Monitoring the Future survey asked about daily vaping this year for first time
Vaping has expanded as a popular method of drug delivery for U.S. teenagers, and one in five students in grades 10 and 12 reported vaping marijuana in the past year, according to results of the 2019 Monitoring the Future survey conducted by the National Institute on Drug Abuse (NIDA).
This year’s findings, announced Dec. 18, continue to illustrate “a clear shift in the pattern of drug taking among teenagers,” said NIDA Director Nora D. Volkow, MD, in a teleconference held to review the results.
Use of alcohol and drugs – including opioids and stimulants – continues to decline among teens, but vaping continues its significant rise, with a surge in marijuana vaping this year.
The increase in past-month marijuana vaping among 12th graders, from 7.5% in 2018 to 14% in 2019, represents the second-largest 1-year jump tracked for any substance in the survey’s history, Dr. Volkow said. The largest jump was the increase in past-month nicotine vaping among 12th-graders from 2017-2018.
“It is very unfortunate that we are seeing the steep rise in the use of vaping devices” because the devices deliver drugs in very high concentration, Dr. Volkow said. The growing popularity of vaping “threatens to undo years of progress protecting the health of adolescents in the U.S.,” Dr. Volkow said in a statement. The Monitoring the Future survey began including vaping questions in 2017.
Monitoring the Future is a national tool to assess drug and alcohol use and related attitudes among adolescent students across the United States. This year’s self-reported survey included 42,531 in grades 8, 10, and 12 from 396 public and private schools.
Nicotine vaping increased from 2018 to 2019 across all three grades; past-month nicotine use equated to 1 in 4, 1 in 5, and 1 in 10 (26%, 20%, and 10%) among 12th, 10th, and 8th graders, respectively, according to the survey. Daily nicotine vaping, measured for the first time this year because of public health concerns, was approximately 12% for 12th graders, 7% for 10th graders, and 2% for 8th graders. Daily marijuana vaping, also measured for the first time this year, was approximately 4%, 3%, and 1% among 12th, 10th, and 8th graders, respectively. Additional findings on the rise of vaping by U.S. teenagers were released Dec. 17 in a research letter published online in JAMA (doi: 10.1001/jama.2019.20185).
Meanwhile, positive trends in this year’s survey included a reduction in the misuse of prescription drugs, including OxyContin, Vicodin, and Adderall, and in the use of traditional cigarettes and other tobacco products, as well as alcohol, noted Richard A. Miech, PhD, MPH, of the University of Michigan, Ann Arbor, principal investigator for Monitoring the Future. However, the challenge of preventing and reducing vaping in teens remains “a whole new uncharted territory,” in part because the design of the vaping devices facilitates discreet use at home and at school, he said.
Physicians and parents have important roles to play in screening for vaping among teens, Dr. Volkow said in a question and answer session. Health care clinicians, including pediatricians and family physicians, “are in a unique position to communicate with their young patients” by educating them about the dangers of vaping, encouraging them to stop if they have started using these devices, and referring them for further treatment if they are showing signs of addiction, she said.
Monitoring the Future was funded by NIDA. The researchers had no disclosures.
Monitoring the Future survey asked about daily vaping this year for first time
Monitoring the Future survey asked about daily vaping this year for first time
Vaping has expanded as a popular method of drug delivery for U.S. teenagers, and one in five students in grades 10 and 12 reported vaping marijuana in the past year, according to results of the 2019 Monitoring the Future survey conducted by the National Institute on Drug Abuse (NIDA).
This year’s findings, announced Dec. 18, continue to illustrate “a clear shift in the pattern of drug taking among teenagers,” said NIDA Director Nora D. Volkow, MD, in a teleconference held to review the results.
Use of alcohol and drugs – including opioids and stimulants – continues to decline among teens, but vaping continues its significant rise, with a surge in marijuana vaping this year.
The increase in past-month marijuana vaping among 12th graders, from 7.5% in 2018 to 14% in 2019, represents the second-largest 1-year jump tracked for any substance in the survey’s history, Dr. Volkow said. The largest jump was the increase in past-month nicotine vaping among 12th-graders from 2017-2018.
“It is very unfortunate that we are seeing the steep rise in the use of vaping devices” because the devices deliver drugs in very high concentration, Dr. Volkow said. The growing popularity of vaping “threatens to undo years of progress protecting the health of adolescents in the U.S.,” Dr. Volkow said in a statement. The Monitoring the Future survey began including vaping questions in 2017.
Monitoring the Future is a national tool to assess drug and alcohol use and related attitudes among adolescent students across the United States. This year’s self-reported survey included 42,531 in grades 8, 10, and 12 from 396 public and private schools.
Nicotine vaping increased from 2018 to 2019 across all three grades; past-month nicotine use equated to 1 in 4, 1 in 5, and 1 in 10 (26%, 20%, and 10%) among 12th, 10th, and 8th graders, respectively, according to the survey. Daily nicotine vaping, measured for the first time this year because of public health concerns, was approximately 12% for 12th graders, 7% for 10th graders, and 2% for 8th graders. Daily marijuana vaping, also measured for the first time this year, was approximately 4%, 3%, and 1% among 12th, 10th, and 8th graders, respectively. Additional findings on the rise of vaping by U.S. teenagers were released Dec. 17 in a research letter published online in JAMA (doi: 10.1001/jama.2019.20185).
Meanwhile, positive trends in this year’s survey included a reduction in the misuse of prescription drugs, including OxyContin, Vicodin, and Adderall, and in the use of traditional cigarettes and other tobacco products, as well as alcohol, noted Richard A. Miech, PhD, MPH, of the University of Michigan, Ann Arbor, principal investigator for Monitoring the Future. However, the challenge of preventing and reducing vaping in teens remains “a whole new uncharted territory,” in part because the design of the vaping devices facilitates discreet use at home and at school, he said.
Physicians and parents have important roles to play in screening for vaping among teens, Dr. Volkow said in a question and answer session. Health care clinicians, including pediatricians and family physicians, “are in a unique position to communicate with their young patients” by educating them about the dangers of vaping, encouraging them to stop if they have started using these devices, and referring them for further treatment if they are showing signs of addiction, she said.
Monitoring the Future was funded by NIDA. The researchers had no disclosures.
Vaping has expanded as a popular method of drug delivery for U.S. teenagers, and one in five students in grades 10 and 12 reported vaping marijuana in the past year, according to results of the 2019 Monitoring the Future survey conducted by the National Institute on Drug Abuse (NIDA).
This year’s findings, announced Dec. 18, continue to illustrate “a clear shift in the pattern of drug taking among teenagers,” said NIDA Director Nora D. Volkow, MD, in a teleconference held to review the results.
Use of alcohol and drugs – including opioids and stimulants – continues to decline among teens, but vaping continues its significant rise, with a surge in marijuana vaping this year.
The increase in past-month marijuana vaping among 12th graders, from 7.5% in 2018 to 14% in 2019, represents the second-largest 1-year jump tracked for any substance in the survey’s history, Dr. Volkow said. The largest jump was the increase in past-month nicotine vaping among 12th-graders from 2017-2018.
“It is very unfortunate that we are seeing the steep rise in the use of vaping devices” because the devices deliver drugs in very high concentration, Dr. Volkow said. The growing popularity of vaping “threatens to undo years of progress protecting the health of adolescents in the U.S.,” Dr. Volkow said in a statement. The Monitoring the Future survey began including vaping questions in 2017.
Monitoring the Future is a national tool to assess drug and alcohol use and related attitudes among adolescent students across the United States. This year’s self-reported survey included 42,531 in grades 8, 10, and 12 from 396 public and private schools.
Nicotine vaping increased from 2018 to 2019 across all three grades; past-month nicotine use equated to 1 in 4, 1 in 5, and 1 in 10 (26%, 20%, and 10%) among 12th, 10th, and 8th graders, respectively, according to the survey. Daily nicotine vaping, measured for the first time this year because of public health concerns, was approximately 12% for 12th graders, 7% for 10th graders, and 2% for 8th graders. Daily marijuana vaping, also measured for the first time this year, was approximately 4%, 3%, and 1% among 12th, 10th, and 8th graders, respectively. Additional findings on the rise of vaping by U.S. teenagers were released Dec. 17 in a research letter published online in JAMA (doi: 10.1001/jama.2019.20185).
Meanwhile, positive trends in this year’s survey included a reduction in the misuse of prescription drugs, including OxyContin, Vicodin, and Adderall, and in the use of traditional cigarettes and other tobacco products, as well as alcohol, noted Richard A. Miech, PhD, MPH, of the University of Michigan, Ann Arbor, principal investigator for Monitoring the Future. However, the challenge of preventing and reducing vaping in teens remains “a whole new uncharted territory,” in part because the design of the vaping devices facilitates discreet use at home and at school, he said.
Physicians and parents have important roles to play in screening for vaping among teens, Dr. Volkow said in a question and answer session. Health care clinicians, including pediatricians and family physicians, “are in a unique position to communicate with their young patients” by educating them about the dangers of vaping, encouraging them to stop if they have started using these devices, and referring them for further treatment if they are showing signs of addiction, she said.
Monitoring the Future was funded by NIDA. The researchers had no disclosures.
The vaping problem
The first time I was sure I was witnessing someone vaping occurred when I saw an alarming cloud of smoke billowing from driver’s side window of the car in front of me. My initial concern was that vehicle was on fire. But none of the other drivers around me seemed concerned and as I pulled up next to the car I could see the driver ostentatiously inhaling deeply in preparation for releasing another monstrous cloud of vapor.
However, you probably have learned, as have I, that most vaping is done furtively. In fact, the pocketability of vaping devices is part of their appeal to teenagers. Hiding a lit cigarette in one’s pocket is something even the most risk-loving adolescent usually won’t attempt. I suspect that regardless of what is in the vapor, the high one can get by putting one over on the school administration by vaping in the school restroom or in the middle of history class is a temptation that many teenagers can’t resist.
Listening to educators, substance abuse counselors, and police officers who have first hand knowledge,
Part of the problem seems to be that vaping was flying under the radar and expanding rapidly long before educators, parents, and I fear physicians woke up to the severity and magnitude of the problem. And now everybody is playing catchup.
Of course the initial, and as yet unconfirmed, notion that e-cigarettes might provide a viable strategy for tobacco withdrawal has added confusion to the mix. It turns out that vaping can provide many orders of magnitude more nicotine in a small volume than cigarettes, which creates an outsized addiction potential for those more vulnerable users – even with a very short history of use. My experts tell me that this level of addiction has forced them to consider strategies and dosages far beyond those they are accustomed to using with patients whose addiction stems from standard cigarette use.
The recent discovery of lung damage related to vaping provided a brief glimmer of hope that fear would turn the tide in the vaping epidemic. But unfortunately the Centers for Disease Control and Prevention did its job too well. Although maybe it was a bit late to uncover the condition, the agency acted quickly to chase down the epidemiology and eventually the chemical responsible for the pulmonary injury. My local experts tell me that, while the cause of the lung damage was still a mystery, they noticed a decline in vaping generated by the fear of this unknown killer. Young people were reporting that they were rethinking their vaping usage. However, once the chemical culprit was identified, their clients felt that they could safely vape again as long as they were more careful in choosing the source of liquid in their devices.
Not surprisingly, the current administration has been providing mixed messages about how it will address vaping. There always will be the argument that if you ban a substance, it will be driven underground and become more difficult to manage. However, in the case of vaping, its appeal and risk to young people and the apparent ineffectiveness of local efforts to control it demand a firm unwavering response at the federal level.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The first time I was sure I was witnessing someone vaping occurred when I saw an alarming cloud of smoke billowing from driver’s side window of the car in front of me. My initial concern was that vehicle was on fire. But none of the other drivers around me seemed concerned and as I pulled up next to the car I could see the driver ostentatiously inhaling deeply in preparation for releasing another monstrous cloud of vapor.
However, you probably have learned, as have I, that most vaping is done furtively. In fact, the pocketability of vaping devices is part of their appeal to teenagers. Hiding a lit cigarette in one’s pocket is something even the most risk-loving adolescent usually won’t attempt. I suspect that regardless of what is in the vapor, the high one can get by putting one over on the school administration by vaping in the school restroom or in the middle of history class is a temptation that many teenagers can’t resist.
Listening to educators, substance abuse counselors, and police officers who have first hand knowledge,
Part of the problem seems to be that vaping was flying under the radar and expanding rapidly long before educators, parents, and I fear physicians woke up to the severity and magnitude of the problem. And now everybody is playing catchup.
Of course the initial, and as yet unconfirmed, notion that e-cigarettes might provide a viable strategy for tobacco withdrawal has added confusion to the mix. It turns out that vaping can provide many orders of magnitude more nicotine in a small volume than cigarettes, which creates an outsized addiction potential for those more vulnerable users – even with a very short history of use. My experts tell me that this level of addiction has forced them to consider strategies and dosages far beyond those they are accustomed to using with patients whose addiction stems from standard cigarette use.
The recent discovery of lung damage related to vaping provided a brief glimmer of hope that fear would turn the tide in the vaping epidemic. But unfortunately the Centers for Disease Control and Prevention did its job too well. Although maybe it was a bit late to uncover the condition, the agency acted quickly to chase down the epidemiology and eventually the chemical responsible for the pulmonary injury. My local experts tell me that, while the cause of the lung damage was still a mystery, they noticed a decline in vaping generated by the fear of this unknown killer. Young people were reporting that they were rethinking their vaping usage. However, once the chemical culprit was identified, their clients felt that they could safely vape again as long as they were more careful in choosing the source of liquid in their devices.
Not surprisingly, the current administration has been providing mixed messages about how it will address vaping. There always will be the argument that if you ban a substance, it will be driven underground and become more difficult to manage. However, in the case of vaping, its appeal and risk to young people and the apparent ineffectiveness of local efforts to control it demand a firm unwavering response at the federal level.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The first time I was sure I was witnessing someone vaping occurred when I saw an alarming cloud of smoke billowing from driver’s side window of the car in front of me. My initial concern was that vehicle was on fire. But none of the other drivers around me seemed concerned and as I pulled up next to the car I could see the driver ostentatiously inhaling deeply in preparation for releasing another monstrous cloud of vapor.
However, you probably have learned, as have I, that most vaping is done furtively. In fact, the pocketability of vaping devices is part of their appeal to teenagers. Hiding a lit cigarette in one’s pocket is something even the most risk-loving adolescent usually won’t attempt. I suspect that regardless of what is in the vapor, the high one can get by putting one over on the school administration by vaping in the school restroom or in the middle of history class is a temptation that many teenagers can’t resist.
Listening to educators, substance abuse counselors, and police officers who have first hand knowledge,
Part of the problem seems to be that vaping was flying under the radar and expanding rapidly long before educators, parents, and I fear physicians woke up to the severity and magnitude of the problem. And now everybody is playing catchup.
Of course the initial, and as yet unconfirmed, notion that e-cigarettes might provide a viable strategy for tobacco withdrawal has added confusion to the mix. It turns out that vaping can provide many orders of magnitude more nicotine in a small volume than cigarettes, which creates an outsized addiction potential for those more vulnerable users – even with a very short history of use. My experts tell me that this level of addiction has forced them to consider strategies and dosages far beyond those they are accustomed to using with patients whose addiction stems from standard cigarette use.
The recent discovery of lung damage related to vaping provided a brief glimmer of hope that fear would turn the tide in the vaping epidemic. But unfortunately the Centers for Disease Control and Prevention did its job too well. Although maybe it was a bit late to uncover the condition, the agency acted quickly to chase down the epidemiology and eventually the chemical responsible for the pulmonary injury. My local experts tell me that, while the cause of the lung damage was still a mystery, they noticed a decline in vaping generated by the fear of this unknown killer. Young people were reporting that they were rethinking their vaping usage. However, once the chemical culprit was identified, their clients felt that they could safely vape again as long as they were more careful in choosing the source of liquid in their devices.
Not surprisingly, the current administration has been providing mixed messages about how it will address vaping. There always will be the argument that if you ban a substance, it will be driven underground and become more difficult to manage. However, in the case of vaping, its appeal and risk to young people and the apparent ineffectiveness of local efforts to control it demand a firm unwavering response at the federal level.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Emergency physicians not yet embracing buprenorphine for opioid users
SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.
“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.
Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.
At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).
Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.
Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.
Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”
Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”
But not all of the findings were grim.
Dr. Edelman said.
According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.
“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.
“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.
Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”
ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.
Dr. Hawk and Dr. Edelman reported no relevant disclosures.
SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.
“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.
Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.
At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).
Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.
Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.
Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”
Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”
But not all of the findings were grim.
Dr. Edelman said.
According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.
“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.
“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.
Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”
ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.
Dr. Hawk and Dr. Edelman reported no relevant disclosures.
SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.
“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.
Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.
At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).
Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.
Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.
Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”
Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”
But not all of the findings were grim.
Dr. Edelman said.
According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.
“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.
“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.
Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”
ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.
Dr. Hawk and Dr. Edelman reported no relevant disclosures.
REPORTING FROM AAAP 2019
In addiction, abusive partners can wreak havoc
Gender-based violence could be driver of opioid epidemic, expert suggests
SAN DIEGO – Many factors drive addiction. But clinicians often fail to address the important role played by abusive intimate partners, a psychiatrist told colleagues at the annual meeting of the American Academy of Addiction Psychiatry.
Violence is not the only source of harm, said Carole Warshaw, MD, as abusers also turn to sabotage, gaslighting, and manipulation – especially when substance users seek help.
“Abusive partners deliberately engage in behaviors designed to undermine their partner’s sanity or sobriety,” said Dr. Warshaw, director of the National Center on Domestic Violence, Trauma & Mental Health in Chicago, in a presentation at the meeting. “We’ve talked a lot about drivers of the opioid epidemic, including pharmaceutical industry greed and disorders of despair. But nobody’s been really talking about gender-based violence as a potential driver of the opioid epidemic, including intimate-partner violence, trafficking, and commercial sex exploitation.”
Dr. Warshaw highlighted the findings of a 2014 study that examined the survey responses of 2,546 adult women (54% white, 19% black, 19% Hispanic) who called the National Domestic Violence Hotline. The study, led by Dr. Warshaw, only included women who had experienced domestic violence and were not in immediate crisis.
The women answered questions about abusive partners, and their responses were often emotional, Dr. Warshaw said. “People would say: ‘No one asked me this before,’ and they’d be in tears. It was just very moving for people to start thinking about this.”
Gaslighting, sabotage, and accusations of mental illness were common. More than 85% of respondents said their current or ex-partner had called them “crazy,” and 74% agreed that “your partner or ex-partner has ... deliberately done things to make you feel like you are going crazy or losing your mind.”
Strategies of abusive partners include sabotaging and discrediting their partners’ attempts at recovery, Dr. Warshaw said. Half of callers agreed that a partner or ex-partner “tried to prevent or discourage you from getting ... help or taking medication you were prescribed for your feelings.”
About 92% of callers who said they’d tried to get help in recent years “reported that their partner or ex-partner had threatened to report their alcohol or other drug use to authorities to keep them from getting something they wanted or needed,” the study found.
All of the abuse can create a kind of addiction feedback loop, she said. “Research has consistently documented that abuse by an intimate partner increases a person’s risk for developing a range of health and mental health conditions – including depression, PTSD, anxiety – that are risk factors for opioid and substance use.”
The toolkit, she said, provides insight into how to integrate questions about abusive partners into your practice and how to partner with domestic violence programs.
Dr. Warshaw reported no relevant disclosures.
Gender-based violence could be driver of opioid epidemic, expert suggests
Gender-based violence could be driver of opioid epidemic, expert suggests
SAN DIEGO – Many factors drive addiction. But clinicians often fail to address the important role played by abusive intimate partners, a psychiatrist told colleagues at the annual meeting of the American Academy of Addiction Psychiatry.
Violence is not the only source of harm, said Carole Warshaw, MD, as abusers also turn to sabotage, gaslighting, and manipulation – especially when substance users seek help.
“Abusive partners deliberately engage in behaviors designed to undermine their partner’s sanity or sobriety,” said Dr. Warshaw, director of the National Center on Domestic Violence, Trauma & Mental Health in Chicago, in a presentation at the meeting. “We’ve talked a lot about drivers of the opioid epidemic, including pharmaceutical industry greed and disorders of despair. But nobody’s been really talking about gender-based violence as a potential driver of the opioid epidemic, including intimate-partner violence, trafficking, and commercial sex exploitation.”
Dr. Warshaw highlighted the findings of a 2014 study that examined the survey responses of 2,546 adult women (54% white, 19% black, 19% Hispanic) who called the National Domestic Violence Hotline. The study, led by Dr. Warshaw, only included women who had experienced domestic violence and were not in immediate crisis.
The women answered questions about abusive partners, and their responses were often emotional, Dr. Warshaw said. “People would say: ‘No one asked me this before,’ and they’d be in tears. It was just very moving for people to start thinking about this.”
Gaslighting, sabotage, and accusations of mental illness were common. More than 85% of respondents said their current or ex-partner had called them “crazy,” and 74% agreed that “your partner or ex-partner has ... deliberately done things to make you feel like you are going crazy or losing your mind.”
Strategies of abusive partners include sabotaging and discrediting their partners’ attempts at recovery, Dr. Warshaw said. Half of callers agreed that a partner or ex-partner “tried to prevent or discourage you from getting ... help or taking medication you were prescribed for your feelings.”
About 92% of callers who said they’d tried to get help in recent years “reported that their partner or ex-partner had threatened to report their alcohol or other drug use to authorities to keep them from getting something they wanted or needed,” the study found.
All of the abuse can create a kind of addiction feedback loop, she said. “Research has consistently documented that abuse by an intimate partner increases a person’s risk for developing a range of health and mental health conditions – including depression, PTSD, anxiety – that are risk factors for opioid and substance use.”
The toolkit, she said, provides insight into how to integrate questions about abusive partners into your practice and how to partner with domestic violence programs.
Dr. Warshaw reported no relevant disclosures.
SAN DIEGO – Many factors drive addiction. But clinicians often fail to address the important role played by abusive intimate partners, a psychiatrist told colleagues at the annual meeting of the American Academy of Addiction Psychiatry.
Violence is not the only source of harm, said Carole Warshaw, MD, as abusers also turn to sabotage, gaslighting, and manipulation – especially when substance users seek help.
“Abusive partners deliberately engage in behaviors designed to undermine their partner’s sanity or sobriety,” said Dr. Warshaw, director of the National Center on Domestic Violence, Trauma & Mental Health in Chicago, in a presentation at the meeting. “We’ve talked a lot about drivers of the opioid epidemic, including pharmaceutical industry greed and disorders of despair. But nobody’s been really talking about gender-based violence as a potential driver of the opioid epidemic, including intimate-partner violence, trafficking, and commercial sex exploitation.”
Dr. Warshaw highlighted the findings of a 2014 study that examined the survey responses of 2,546 adult women (54% white, 19% black, 19% Hispanic) who called the National Domestic Violence Hotline. The study, led by Dr. Warshaw, only included women who had experienced domestic violence and were not in immediate crisis.
The women answered questions about abusive partners, and their responses were often emotional, Dr. Warshaw said. “People would say: ‘No one asked me this before,’ and they’d be in tears. It was just very moving for people to start thinking about this.”
Gaslighting, sabotage, and accusations of mental illness were common. More than 85% of respondents said their current or ex-partner had called them “crazy,” and 74% agreed that “your partner or ex-partner has ... deliberately done things to make you feel like you are going crazy or losing your mind.”
Strategies of abusive partners include sabotaging and discrediting their partners’ attempts at recovery, Dr. Warshaw said. Half of callers agreed that a partner or ex-partner “tried to prevent or discourage you from getting ... help or taking medication you were prescribed for your feelings.”
About 92% of callers who said they’d tried to get help in recent years “reported that their partner or ex-partner had threatened to report their alcohol or other drug use to authorities to keep them from getting something they wanted or needed,” the study found.
All of the abuse can create a kind of addiction feedback loop, she said. “Research has consistently documented that abuse by an intimate partner increases a person’s risk for developing a range of health and mental health conditions – including depression, PTSD, anxiety – that are risk factors for opioid and substance use.”
The toolkit, she said, provides insight into how to integrate questions about abusive partners into your practice and how to partner with domestic violence programs.
Dr. Warshaw reported no relevant disclosures.
REPORTING FROM AAAP 2019
Addiction specialists: Cannabis policies should go up in smoke
SAN DIEGO – Addiction specialists have a message for American policymakers who are rushing to create laws to allow the use of medical and recreational marijuana: You’re doing it wrong, but we know how you can do it right.
“We can have spirited debates on these policies, recreational, medical decriminalization, etc. But we can’t argue how we’ve done a poor job implementing these policies in the United States,” psychiatrist Kevin P. Hill, MD, of Harvard Medical School, Boston, said in a symposium about cannabis policy at the annual meeting of the American Academy of Addiction Psychiatry.
The AAAP is proposing a “model state law” regarding cannabis. Among other things, the proposal urges states to:
- Ban recreational use of cannabis until the age of 21, and perhaps even until 25.
- Not denote psychiatric indications such as posttraumatic stress disorder, anxiety, and depression as qualifying conditions for the use of medical marijuana.
- Educate the public about potential harms of cannabis.
- Provide state-level regulation that includes funding of high-grade analytic equipment to test cannabis.
- Maintain a public registry that reports annually on adverse outcomes.
Research suggests that marijuana use has spiked in recent years, Dr. Hill said. Meanwhile, states have dramatically broadened the legality of marijuana. According to the National Conference of State Legislatures, 33 states and the District of Columbia allow the medical use of marijuana. Of those, 11 states and the District of Columbia also allow the adult use of recreational marijuana. Several other states allow access to cannabidiol (CBD)/low-THC products in some cases (www.ncsl.org/research/health/state-medical-marijuana-laws.aspx).
The problem, Dr. Hill said, is that there’s “a big gap between what the science says and what the laws are saying, unfortunately. So we’re in this precarious spot.”
He pointed to his own 2015 review of cannabinoid studies that found high-quality evidence for an effect for just three conditions – chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis. The study notes that Food and Drug Administration–approved cannabinoids are also available to treat nausea and vomiting linked to chemotherapy and to boost appetite in patients with wasting disease. (JAMA. 2015 Jun 23-30;313(24):2474-83).
However, states have listed dozens of conditions – 53 overall – as qualifying conditions for the use of medical marijuana, Dr. Hill said. And, he said, “the reality is that a lot of people who are using medical cannabis don’t have any of these conditions,” he said.
Researchers at the symposium focused on the use of cannabis as a treatment for addiction and other psychiatric illnesses.
Four states have legalized the use of cannabis in patients with opioid use disorder, said cannabis researcher Ziva D. Cooper, PhD, of the University of California, Los Angeles, who spoke at the symposium. But can cannabis actually reduce opioid use? Preliminary clinical data suggest THC could reduce opioid use, Dr. Cooper said, while population and state-level research is mixed.
What about other mental health disorders? Posttraumatic stress disorder is commonly listed as a qualifying condition for medical marijuana use in state laws. And some states, like California, give physicians wide leeway in recommending marijuana use for patients with conditions that aren’t listed in the law.
However, symposium speaker and psychiatrist Frances R. Levin, MD, of New York State Psychiatric Institute, pointed to a 2019 review that suggests “there is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, posttraumatic stress disorder, or psychosis” (Lancet Psychiatry. 2019 Dec;6[12]:995-1010).
What now? The AAAP hopes lawmakers will pay attention to its proposed model state law, which will be published soon in the association’s journal, the American Journal on Addictions.
SAN DIEGO – Addiction specialists have a message for American policymakers who are rushing to create laws to allow the use of medical and recreational marijuana: You’re doing it wrong, but we know how you can do it right.
“We can have spirited debates on these policies, recreational, medical decriminalization, etc. But we can’t argue how we’ve done a poor job implementing these policies in the United States,” psychiatrist Kevin P. Hill, MD, of Harvard Medical School, Boston, said in a symposium about cannabis policy at the annual meeting of the American Academy of Addiction Psychiatry.
The AAAP is proposing a “model state law” regarding cannabis. Among other things, the proposal urges states to:
- Ban recreational use of cannabis until the age of 21, and perhaps even until 25.
- Not denote psychiatric indications such as posttraumatic stress disorder, anxiety, and depression as qualifying conditions for the use of medical marijuana.
- Educate the public about potential harms of cannabis.
- Provide state-level regulation that includes funding of high-grade analytic equipment to test cannabis.
- Maintain a public registry that reports annually on adverse outcomes.
Research suggests that marijuana use has spiked in recent years, Dr. Hill said. Meanwhile, states have dramatically broadened the legality of marijuana. According to the National Conference of State Legislatures, 33 states and the District of Columbia allow the medical use of marijuana. Of those, 11 states and the District of Columbia also allow the adult use of recreational marijuana. Several other states allow access to cannabidiol (CBD)/low-THC products in some cases (www.ncsl.org/research/health/state-medical-marijuana-laws.aspx).
The problem, Dr. Hill said, is that there’s “a big gap between what the science says and what the laws are saying, unfortunately. So we’re in this precarious spot.”
He pointed to his own 2015 review of cannabinoid studies that found high-quality evidence for an effect for just three conditions – chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis. The study notes that Food and Drug Administration–approved cannabinoids are also available to treat nausea and vomiting linked to chemotherapy and to boost appetite in patients with wasting disease. (JAMA. 2015 Jun 23-30;313(24):2474-83).
However, states have listed dozens of conditions – 53 overall – as qualifying conditions for the use of medical marijuana, Dr. Hill said. And, he said, “the reality is that a lot of people who are using medical cannabis don’t have any of these conditions,” he said.
Researchers at the symposium focused on the use of cannabis as a treatment for addiction and other psychiatric illnesses.
Four states have legalized the use of cannabis in patients with opioid use disorder, said cannabis researcher Ziva D. Cooper, PhD, of the University of California, Los Angeles, who spoke at the symposium. But can cannabis actually reduce opioid use? Preliminary clinical data suggest THC could reduce opioid use, Dr. Cooper said, while population and state-level research is mixed.
What about other mental health disorders? Posttraumatic stress disorder is commonly listed as a qualifying condition for medical marijuana use in state laws. And some states, like California, give physicians wide leeway in recommending marijuana use for patients with conditions that aren’t listed in the law.
However, symposium speaker and psychiatrist Frances R. Levin, MD, of New York State Psychiatric Institute, pointed to a 2019 review that suggests “there is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, posttraumatic stress disorder, or psychosis” (Lancet Psychiatry. 2019 Dec;6[12]:995-1010).
What now? The AAAP hopes lawmakers will pay attention to its proposed model state law, which will be published soon in the association’s journal, the American Journal on Addictions.
SAN DIEGO – Addiction specialists have a message for American policymakers who are rushing to create laws to allow the use of medical and recreational marijuana: You’re doing it wrong, but we know how you can do it right.
“We can have spirited debates on these policies, recreational, medical decriminalization, etc. But we can’t argue how we’ve done a poor job implementing these policies in the United States,” psychiatrist Kevin P. Hill, MD, of Harvard Medical School, Boston, said in a symposium about cannabis policy at the annual meeting of the American Academy of Addiction Psychiatry.
The AAAP is proposing a “model state law” regarding cannabis. Among other things, the proposal urges states to:
- Ban recreational use of cannabis until the age of 21, and perhaps even until 25.
- Not denote psychiatric indications such as posttraumatic stress disorder, anxiety, and depression as qualifying conditions for the use of medical marijuana.
- Educate the public about potential harms of cannabis.
- Provide state-level regulation that includes funding of high-grade analytic equipment to test cannabis.
- Maintain a public registry that reports annually on adverse outcomes.
Research suggests that marijuana use has spiked in recent years, Dr. Hill said. Meanwhile, states have dramatically broadened the legality of marijuana. According to the National Conference of State Legislatures, 33 states and the District of Columbia allow the medical use of marijuana. Of those, 11 states and the District of Columbia also allow the adult use of recreational marijuana. Several other states allow access to cannabidiol (CBD)/low-THC products in some cases (www.ncsl.org/research/health/state-medical-marijuana-laws.aspx).
The problem, Dr. Hill said, is that there’s “a big gap between what the science says and what the laws are saying, unfortunately. So we’re in this precarious spot.”
He pointed to his own 2015 review of cannabinoid studies that found high-quality evidence for an effect for just three conditions – chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis. The study notes that Food and Drug Administration–approved cannabinoids are also available to treat nausea and vomiting linked to chemotherapy and to boost appetite in patients with wasting disease. (JAMA. 2015 Jun 23-30;313(24):2474-83).
However, states have listed dozens of conditions – 53 overall – as qualifying conditions for the use of medical marijuana, Dr. Hill said. And, he said, “the reality is that a lot of people who are using medical cannabis don’t have any of these conditions,” he said.
Researchers at the symposium focused on the use of cannabis as a treatment for addiction and other psychiatric illnesses.
Four states have legalized the use of cannabis in patients with opioid use disorder, said cannabis researcher Ziva D. Cooper, PhD, of the University of California, Los Angeles, who spoke at the symposium. But can cannabis actually reduce opioid use? Preliminary clinical data suggest THC could reduce opioid use, Dr. Cooper said, while population and state-level research is mixed.
What about other mental health disorders? Posttraumatic stress disorder is commonly listed as a qualifying condition for medical marijuana use in state laws. And some states, like California, give physicians wide leeway in recommending marijuana use for patients with conditions that aren’t listed in the law.
However, symposium speaker and psychiatrist Frances R. Levin, MD, of New York State Psychiatric Institute, pointed to a 2019 review that suggests “there is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, posttraumatic stress disorder, or psychosis” (Lancet Psychiatry. 2019 Dec;6[12]:995-1010).
What now? The AAAP hopes lawmakers will pay attention to its proposed model state law, which will be published soon in the association’s journal, the American Journal on Addictions.
REPORTING FROM AAAP 2019
Does using e-cigarettes increase cigarette smoking in adolescents?
EVIDENCE SUMMARY
A meta-analysis of 9 prospective cohort studies (total 17,389 patients) at least 6 months in duration evaluated the association between e-cigarette exposure and subsequent cigarette smoking in adolescents and young adults.1 It found that smoking was more prevalent in ever-users of e-cigarettes than nonusers at 1 year (23.3% vs 7.2%; odds ratio [OR] = 3.5; 95% confidence interval [CI], 2.38-5.16). The association was even stronger among recent users (within 30 days) of e-cigarettes compared with nonusers (21.5% vs 4.6%; OR = 4.28; 95% CI, 2.52-7.27). The mean age of approximately 80% of participants was 20 years or younger.
Further studies also support a link between e-cigarette and cigarette use
Four subsequent cohort studies also found links between e-cigarette exposure and any level of cigarette smoking (TABLE).2-5 A Canadian study of high school students reported a positive association between recent e-cigarette use (within the previous 30 days) and subsequent daily cigarette usage (OR = 1.79; 95% CI, 1.41-2.28).2 A British study that documented the largest association uniquely validated smoking status with carbon monoxide testing.3 A study of Mexican adolescents found that adolescents who tried e-cigarettes were more likely to smoke cigarettes and also reported an association between e-cigarette use and marijuana use (relative risk [RR] = 1.93; 95% CI, 1.14–3.28).4 A California study that evaluated e-cigarette nicotine level and subsequent cigarette smoking found a dose-dependent response, suggesting an association between nicotine concentration and subsequent uptake of cigarettes.5
RECOMMENDATIONS
A policy statement from The American Academy of Pediatrics Section on Tobacco Control states that youth who use e-cigarettes are more likely to use cigarettes and other tobacco products.6 It recommends that physicians screen patients for use of electronic nicotine delivery systems (ENDS), counsel about immediate and long-term harms and the importance of not using ENDS, and offer current users tobacco cessation counseling (with Food and Drug Administration-approved tobacco dependence treatment).
Editor’s takeaway
While these cohort studies don’t definitively prove causation, they provide the best quality evidence that we are likely to see in support of counseling adolescents against using e-cigarettes, educating them about harms, and offering tobacco cessation measures when appropriate.
1. Soneji S, Barrington-Trimis JL, Willis TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults, a systematic review and meta-analysis. JAMA Pediatr. 2017;171:788-797.
2. Hammond D, Reid JL, Cole AG, et al. Electronic cigarette use and smoking initiation among youth: a longitudinal cohort study. CMAJ. 2017;189:E1328-E1336.
3. Conner M, Grogan S, Simms-Ellis R, et al. Do electronic cigarettes increase cigarette smoking in UK adolescents? Evidence from a 12-month prospective study. Tob Control. 2018;27:365-372.
4. Lozano P, Barrientos-Gutierrez I, Arillo-Santillan E, et al. A longitudinal study of electronic cigarette use and onset of conventional cigarette smoking and marijuana use among Mexican adolescents. Drug Alcohol Depend. 2017;180:427-430.
5. Goldenson NI, Leventhal AM, Stone MD, et al. Associations of electronic cigarette nicotine concentration with subsequent cigarette smoking and vaping levels in adolescents. JAMA Pediatr. 2017;171:1192-1199.
6. Walley SC, Jenssen BP; Section on Tobacco Control. Electronic nicotine delivery systems. Pediatrics. 2015;136:1018-1026.
EVIDENCE SUMMARY
A meta-analysis of 9 prospective cohort studies (total 17,389 patients) at least 6 months in duration evaluated the association between e-cigarette exposure and subsequent cigarette smoking in adolescents and young adults.1 It found that smoking was more prevalent in ever-users of e-cigarettes than nonusers at 1 year (23.3% vs 7.2%; odds ratio [OR] = 3.5; 95% confidence interval [CI], 2.38-5.16). The association was even stronger among recent users (within 30 days) of e-cigarettes compared with nonusers (21.5% vs 4.6%; OR = 4.28; 95% CI, 2.52-7.27). The mean age of approximately 80% of participants was 20 years or younger.
Further studies also support a link between e-cigarette and cigarette use
Four subsequent cohort studies also found links between e-cigarette exposure and any level of cigarette smoking (TABLE).2-5 A Canadian study of high school students reported a positive association between recent e-cigarette use (within the previous 30 days) and subsequent daily cigarette usage (OR = 1.79; 95% CI, 1.41-2.28).2 A British study that documented the largest association uniquely validated smoking status with carbon monoxide testing.3 A study of Mexican adolescents found that adolescents who tried e-cigarettes were more likely to smoke cigarettes and also reported an association between e-cigarette use and marijuana use (relative risk [RR] = 1.93; 95% CI, 1.14–3.28).4 A California study that evaluated e-cigarette nicotine level and subsequent cigarette smoking found a dose-dependent response, suggesting an association between nicotine concentration and subsequent uptake of cigarettes.5
RECOMMENDATIONS
A policy statement from The American Academy of Pediatrics Section on Tobacco Control states that youth who use e-cigarettes are more likely to use cigarettes and other tobacco products.6 It recommends that physicians screen patients for use of electronic nicotine delivery systems (ENDS), counsel about immediate and long-term harms and the importance of not using ENDS, and offer current users tobacco cessation counseling (with Food and Drug Administration-approved tobacco dependence treatment).
Editor’s takeaway
While these cohort studies don’t definitively prove causation, they provide the best quality evidence that we are likely to see in support of counseling adolescents against using e-cigarettes, educating them about harms, and offering tobacco cessation measures when appropriate.
EVIDENCE SUMMARY
A meta-analysis of 9 prospective cohort studies (total 17,389 patients) at least 6 months in duration evaluated the association between e-cigarette exposure and subsequent cigarette smoking in adolescents and young adults.1 It found that smoking was more prevalent in ever-users of e-cigarettes than nonusers at 1 year (23.3% vs 7.2%; odds ratio [OR] = 3.5; 95% confidence interval [CI], 2.38-5.16). The association was even stronger among recent users (within 30 days) of e-cigarettes compared with nonusers (21.5% vs 4.6%; OR = 4.28; 95% CI, 2.52-7.27). The mean age of approximately 80% of participants was 20 years or younger.
Further studies also support a link between e-cigarette and cigarette use
Four subsequent cohort studies also found links between e-cigarette exposure and any level of cigarette smoking (TABLE).2-5 A Canadian study of high school students reported a positive association between recent e-cigarette use (within the previous 30 days) and subsequent daily cigarette usage (OR = 1.79; 95% CI, 1.41-2.28).2 A British study that documented the largest association uniquely validated smoking status with carbon monoxide testing.3 A study of Mexican adolescents found that adolescents who tried e-cigarettes were more likely to smoke cigarettes and also reported an association between e-cigarette use and marijuana use (relative risk [RR] = 1.93; 95% CI, 1.14–3.28).4 A California study that evaluated e-cigarette nicotine level and subsequent cigarette smoking found a dose-dependent response, suggesting an association between nicotine concentration and subsequent uptake of cigarettes.5
RECOMMENDATIONS
A policy statement from The American Academy of Pediatrics Section on Tobacco Control states that youth who use e-cigarettes are more likely to use cigarettes and other tobacco products.6 It recommends that physicians screen patients for use of electronic nicotine delivery systems (ENDS), counsel about immediate and long-term harms and the importance of not using ENDS, and offer current users tobacco cessation counseling (with Food and Drug Administration-approved tobacco dependence treatment).
Editor’s takeaway
While these cohort studies don’t definitively prove causation, they provide the best quality evidence that we are likely to see in support of counseling adolescents against using e-cigarettes, educating them about harms, and offering tobacco cessation measures when appropriate.
1. Soneji S, Barrington-Trimis JL, Willis TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults, a systematic review and meta-analysis. JAMA Pediatr. 2017;171:788-797.
2. Hammond D, Reid JL, Cole AG, et al. Electronic cigarette use and smoking initiation among youth: a longitudinal cohort study. CMAJ. 2017;189:E1328-E1336.
3. Conner M, Grogan S, Simms-Ellis R, et al. Do electronic cigarettes increase cigarette smoking in UK adolescents? Evidence from a 12-month prospective study. Tob Control. 2018;27:365-372.
4. Lozano P, Barrientos-Gutierrez I, Arillo-Santillan E, et al. A longitudinal study of electronic cigarette use and onset of conventional cigarette smoking and marijuana use among Mexican adolescents. Drug Alcohol Depend. 2017;180:427-430.
5. Goldenson NI, Leventhal AM, Stone MD, et al. Associations of electronic cigarette nicotine concentration with subsequent cigarette smoking and vaping levels in adolescents. JAMA Pediatr. 2017;171:1192-1199.
6. Walley SC, Jenssen BP; Section on Tobacco Control. Electronic nicotine delivery systems. Pediatrics. 2015;136:1018-1026.
1. Soneji S, Barrington-Trimis JL, Willis TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults, a systematic review and meta-analysis. JAMA Pediatr. 2017;171:788-797.
2. Hammond D, Reid JL, Cole AG, et al. Electronic cigarette use and smoking initiation among youth: a longitudinal cohort study. CMAJ. 2017;189:E1328-E1336.
3. Conner M, Grogan S, Simms-Ellis R, et al. Do electronic cigarettes increase cigarette smoking in UK adolescents? Evidence from a 12-month prospective study. Tob Control. 2018;27:365-372.
4. Lozano P, Barrientos-Gutierrez I, Arillo-Santillan E, et al. A longitudinal study of electronic cigarette use and onset of conventional cigarette smoking and marijuana use among Mexican adolescents. Drug Alcohol Depend. 2017;180:427-430.
5. Goldenson NI, Leventhal AM, Stone MD, et al. Associations of electronic cigarette nicotine concentration with subsequent cigarette smoking and vaping levels in adolescents. JAMA Pediatr. 2017;171:1192-1199.
6. Walley SC, Jenssen BP; Section on Tobacco Control. Electronic nicotine delivery systems. Pediatrics. 2015;136:1018-1026.
EVIDENCE-BASED ANSWER:
Probably. Electronic cigarette (e-cigarette) use by adolescents is associated with a 2- to 4-fold increase in cigarette smoking over the next year (strength of recommendation: A, meta-analysis and subsequent prospective cohort studies).
A patient-centered approach to tapering opioids
Many Americans who are treated with prescription opioid analgesics would be better off with less opioid or none at all. To that end, published opioid prescribing guidelines do provide guidance on the mechanics of tapering patients off opioids1-4—but they have a major flaw: They do not adequately account for the fact that people who have a diagnosis of chronic pain are a heterogeneous group and require diagnosis-specific treatment planning. A patient-centered approach to opioid tapers must account for the reality that many people who are given a prescription for an opioid to treat pain have significant mental health conditions—for which opioids act as a psychotropic agent. An opioid taper must therefore address psychological trauma, in particular.5 (See “Tapering and harm-reduction strategies have failed.”6-14)
SIDEBAR
Tapering and harm-reduction strategies have failed
Efforts to address the rising number of overdose events that involve opioids began in earnest in 2010. In a 2011 Government Accountability Office report to Congress, the Drug Enforcement Agency reported that “the number of regulatory investigations (of medical providers who prescribed opioids) tripled between fiscal years 2009- 2010.”6
How has it gone since 2010? High-dosage prescribing of opioids has fallen by 48% since 2011, yet the decline has not reduced overdose events of any kind.7,8 Just the opposite: The 19,000 overdose deaths recorded in 2010 involving any opioid increased to 49,068 by 2017, the National Institute on Drug Abuse reports.9 The increase in opioid overdose deaths is fueled by a recent 9-fold increase in consumption of the synthetic opioid fentanyl: “The rate of drug overdose deaths involving synthetic opioids other than methadone … increased on average by 8% per year from 1999 through 2013 and by 71% per year from 2013 through 2017.”10
These and other statistics document only a modest rise in deaths that involve prescription opioids: from 15,000 in 2010 to 19,000 in 2016.9,10 Since 2010, the crisis of opioid overdose deaths burns hotter, and the pattern of opioid use has shifted from prescription drugs to much deadlier illicit drugs, such as heroin.
Interventions have not been successful overall. Results of research focused on the impact of opioid tapering and harm-reduction strategies implemented this decade are likewise discouraging. In 2018, the US Department of Veterans Affairs reported that opioid discontinuation was not associated with a reduction in overdose but was associated with an increase in suicide.11,12 Von Korff and colleagues, in a 2017 report, concluded that “Long-term implementation of opioid dose and risk reduction initiatives [in Washington state] was not associated with lower rates of prescription opioid use disorder among prevalent [chronic opioid therapy] patients.”13
Evidence suggests that efforts to address the opioid crisis of the past decade have had an effect that is the opposite of what was intended. The federal government recognized this in April 2019 in a Drug Safety Communication: “The US Food and Drug Administration (FDA) has received reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.”14
In this article, we present an evidence-based consensus approach to opioid tapering for your practice that is informed by a broader understanding of why patients take prescription opioids and why they, occasionally, switch to illicit drugs when their prescription is tapered. This consensus approach is based on the experience of the authors, members of the pain faculty of Project ECHO (Extension for Community Healthcare Outcomes) of the ECHO Institute, a worldwide initiative that uses adult learning techniques and interactive video technology to connect community providers with specialists at centers of excellence in regular real-time collaborative sessions. We are variously experts in pain medicine, primary care, psychology, addiction medicine, pharmacy, behavioral health therapy, occupational medicine, and Chinese medicine.
Why Americans obtain prescription opioids
There are 4 principal reasons why patients obtain prescription opioids, beyond indicated analgesic uses:
1. Patients seek the antianxiety and antidepressant effects of opioids. Multiple converging lines of evidence suggest that antianxiety and antidepressant effects of opioids are a significant reason that patients in the United States persist in requesting prescriptions for opioids:
- In our experience with more than 500 primary care telemedicine case presentations, at least 50% of patients say that the main effect of opioids prescribed for them is “it makes me feel calm” or “more relaxed.”
- In a 2007 survey of 91,823 US residents older than 18 years, nonmedical use of opioids was statistically associated with panic, social anxiety, and depressive symptoms.15
- Ten years later, Von Korff and colleagues found that more than half of opioid prescriptions written in the United States were for the small percentage of patients who have a diagnosis of serious anxiety or depression.13
- In 2016, Yovell and colleagues reported that ultra-low-dosage buprenorphine markedly reduced suicidal ideation over 4 weeks in 62 patients with varied levels of depression.16
There is also mechanistic evidence that the antianxiety and antidepressant effects of opioids are significant reasons Americans persist in requesting prescription opioids. The literature suggests that opioid receptors play a role in mood regulation, including alleviation of depression and anxiety; recent research suggests that oxycodone might be a unique mood-altering drug compared to other common prescription opioids because of its ability to affect mood through the δ opioid receptor.17-20
It should not be a surprise that Americans often turn to opioids to address posttraumatic stress disorder (PTSD), anxiety, and depression. A recent study of the state of the US mental health system concluded that mental health services in the United States are inadequate—despite evidence that > 50% of Americans seek, or consider seeking, treatment for mental health problems for themselves or others.21
2. Patients experience pain unrelated to tissue damage. Rather, they are in pain “for psychological reasons.”22 In 2016, Davis and Vanderah wrote: “We theorize that a functional change in the [central nervous system] can occur in response to certain emotional states or traumatic experiences (eg, child abuse, assault, accidents).” They connect this change to central sensitization and a reduced pain-perception threshold,23 and strongly suspect that many patients with chronic pain have undiagnosed and untreated psychological trauma that has changed the way their central nervous system processes sensory stimuli. The authors call this “trauma-induced hyperalgesia.”
Continue to: Psychological trauma...
Psychological trauma is uniquely capable of producing hyperalgesia, compared to anxiety or depression. In a study of veterans, Defrin and colleagues demonstrated hyperalgesia in patients who had a diagnosis of PTSD but not in controls group who had an anxiety disorder only.24
To support successful opioid tapering, trauma-induced hyperalgesia, when present, must be addressed. Treatment of what the International Association for the Study of Pain calls “pain due to psychological factors”22 requires specific trauma therapy. However, our experience validates what researchers have to say about access to treatment of psychological trauma in the United States: “…[C]linical research has identified certain psychological interventions that effectively ameliorate the symptoms of PTSD. But most people struggling with PTSD don’t receive those treatments.”25
We have no doubt that this is due, in part, to underdiagnosis of psychological trauma, even in mental health clinics. According to Miele and colleagues, “PTSD remains largely undiagnosed and undertreated in mental health outpatients, even in teaching hospitals, with diagnosis rates as low as 4% while published prevalence is between 7% and 50% in this population.”26
3. Patients suffer from opioid use disorder (OUD) and complain of pain to obtain opioids by prescription. For patients with OUD, their use is out of control; they devote increasing mental and physical resources to obtaining, using, and recovering from substances; and they continue to use despite adverse consequences.27 The prevalence of OUD in primary care clinics varies strikingly by the location of clinics. In Washington state, the prevalence of moderate and severe OUD in a large population of patients who had been prescribed opioids through primary care clinics was recently determined to be between 21.5% and 23.9%.13
4. Patients are obtaining opioid prescriptions for people other than themselves. While this is a reason that patients obtain opioid prescriptions, it is not necessarily common. Statistics show that the likelihood of a prescription being diverted intentionally is low: Dart and colleagues found that diversion has become uncommon in the general population.28
Continue to: Why we taper opioid analgesics
Why we taper opioid analgesics
Reasons for an opioid taper include concern that the patient has, or will develop, an OUD; will experience accidental or intentional overdose; might be diverting opioids; is not benefiting from opioid therapy for pain; or is experiencing severe adverse effects. A patient who has nociceptive pain and might have opioid-induced hyperalgesia will require a much different opioid taper plan than a patient with untreated PTSD or a patient with severe OUD.
Misunderstanding can lead to inappropriate tapering
We often encounter primary care providers who believe that a large percentage of patients on chronic opioid therapy inevitably develop OUD. This is a common reason for initiating opioid taper. Most patients on a chronic opioid do become physically dependent, but only a small percentage of patients develop psychological dependence (ie, addiction or OUD).29
Physical dependence is “a state of adaptation that is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.”30 Symptoms of opioid withdrawal include muscle aches; abdominal cramping; increased lacrimation, rhinorrhea, and perspiration; diarrhea; agitation and anxiety; insomnia; and piloerection. Opioid withdrawal symptoms are caused by physical dependence, not by addiction. They can be mitigated by tapering slowly and instituting adjuvant medications, such as clonidine, to attenuate symptoms.
Psychological dependence, or addiction (that is, OUD, as described in the Diagnostic and Statistical Manual of Mental Disorders 5th edition27), comprises primarily 3 behavioral criteria:
- Loss of control of the medication, with compulsive use
- Continued use despite adverse consequences of using opioids, such as arrest for driving under the influence and deterioration of social, family, or work performance
- Obsession or preoccupation with obtaining and using the substance. In properly selected chronic opioid therapy patients, there is evidence that new-onset OUD is not as common as has been thought. A recent study of the risk for opioid addiction after use of an opioid for ≥ 90 days for chronic noncancer pain found that the absolute rate of de novo OUD among patients treated for 90 days was 0.72%.29 A systematic review by Fishbain and colleagues of 24 studies of opioid-exposed patients found a risk of 3.27% overall—0.19% for patients who did not have a history of abuse or addiction.31 As Director of the National Institute on Drug Abuse Norma Volkow, MD, wrote in 2016: “Addiction occurs in only a small percentage of people who are exposed to opioids—even among those with preexisting vulnerabilities.”32
Assessment should focus on why the patient is taking an opioid
A strong case can be made that less opioid is better for many of the people for whom these medications are prescribed for chronic noncancer pain. However, a one-size-fits-all dosage reduction and addiction-focused approach to opioid tapering has not worked: The assessment and treatment paradigm must change, in our view.
Continue to: During assessment...
During assessment, we must adopt the means to identify the reason that a patient is using a prescription opioid. It is of particular importance that we identify patients using opioids for their psychotropic properties, particularly when the goal is to cope with the effects of psychological trauma. The subsequent treatment protocol will then need to include time for effective, evidence-based behavioral health treatment of anxiety, PTSD, or depression. If opioids are serving primarily as psychotropic medication, an attempt to taper before establishing effective behavioral health treatment might lead the patient to pursue illegal means of procuring opioid medication.
We acknowledge that primary care physicians are not reimbursed for trauma screening and that evidence-based intensive trauma treatment is generally unavailable in the United States. Both of these shortcomings must be corrected if we want to stem the opioid crisis.
If diversion is suspected and there is evidence that the patient is not currently taking prescribed opioids (eg, a negative urine drug screen), discontinuing the opioid prescription is the immediate next step for the sake of public safety.
SIDEBAR
2 decisions to make before continuing to prescribe an opioid for chronic noncancer pain
#1 Should I provide the patient with a prescription for an opioid for a few days, while I await more information?a
Yes. Writing a prescription is a reasonable decision if all of the following apply:
- You do not have significant suspicion of diversion (based on a clinical interview).
- You do not suspect an active addiction disorder, based on the score of the 10-question Drug Abuse Screening Test (DAST-10) and on a clinical interview. (DAST-10 is available at: https://cde.drugabuse.gov/instrument/e9053390-ee9c-9140-e040-bb89ad433d69.)
- The patient is likely to experience withdrawal symptoms if you don’t provide the medication immediately.
- The patient’s pain and function are likely to be impaired if you do not provide the medication.
- The patient does not display altered mental status during the visit (eg, drowsy, slurred speech).
No. If writing a prescription for an opioid for a few days does not seem to be a reasonable decision because the criteria above are not met, but withdrawal symptoms are likely, you can prescribe medication to mitigate symptoms or refer the patient for treatment of withdrawal.
#2 I’ve decided to provide the patient with a prescription for an opioid. For how many days should I write it?
The usual practice, for a patient whose case is familiar to you, is to prescribe a 1-month supply.
However, if any 1 of the following criteria is met, prescribing a 1-month supply is unsafe under most circumstances:
- An unstable social or living environment places the patient at risk by possessing a supply of opioids (based on a clinical interview).
- You suspect an unstable or severe behavioral health condition or a mental health diagnosis (based on a clinical interview or on the patient record from outside your practice).
- The patient scores as “high risk” on the Opioid Risk Tool (ORT; www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf), Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP-R; www.ncbi.nlm.nih.gov/pmc/articles/PMC4706778/), or a similar opioid risk assessment tool.
When 1 or more of these exclusionary criteria are met, you have 3 options:
- Prescribe an opioid for a brief duration and see the patient often.
- Do not prescribe an opioid; instead, refer the patient as necessary for treatment of withdrawal.
- Refer the patient for treatment of the underlying behavioral health condition.
a Additional information might include findings from consultants you’ve engaged regarding the patient’s diagnosis; a response to your call from a past prescriber; urine drug screen results; and results of a prescription monitoring program check.
Considering a taper? Take this 5-step approach
Once it appears that tapering an opioid is indicated, we propose that you take the following steps:
- Establish whether it is safe to continue prescribing (follow the route provided in “2 decisions to make before continuing to prescribe an opioid for chronic noncancer pain”); if continuing it is not safe, take steps to protect the patient and the community
- Determine whether assessment by a trauma-informed behavioral health expert is needed, assuming that, in your judgment, it is safe to continue the opioid (TABLE33). When behavioral health assessment is needed, you need 3 questions answered by that assessment: (1) Are psychological factors present that might put the patient at risk during an opioid taper? (2) What are those factors? (3) What needs to done about them before the taper is started? Recalling that psychological trauma often is not assessed by behavioral health colleagues, it is necessary to provide the behavioral health provider with a specific request to assess trauma burden, and state the physical diagnoses that are causing pain or provide a clear statement that no such diagnoses can be made. (See the FIGURE, which we developed in conjunction with behavioral health colleagues to help the consultant understand what the primary care physician needs from a behavioral health assessment.)
- Obtain consultation from a physical therapist, pain medicine specialist, and, if possible, an alternative or complementary medicine provider to determine what nonpharmacotherapeutic modalities can be instituted to treat pain before tapering the opioid.
- Initiate the Screening, Brief Intervention and Referral to Treatment (SBIRT) approach if OUD is suspected (www.samhsa.gov/sbirt).34 This motivational interviewing tool identifies patients with a substance use disorder, severity of use, and appropriate level of treatment. (If OUD is suspected during assessment, next steps are to stop prescribing and implement harm-reduction strategies, such as primary care level medically assisted treatment [MAT] with buprenorphine, followed by expert behavioral health-centered addiction treatment.)
- Experiment with dosage reduction according to published guidance, if (1) psychological factors are absent or have been adequately addressed, according to the behavioral health consultant, and (2) nonpharmacotherapeutic strategies are in place.8-11
Shifting to a patient-centered approach
The timing and choice of opioid tapers, in relation to harm reduction and intervention targeting the root cause of a patient’s complaint of pain, have not been adequately explored. In our practice, we’ve shifted from an addiction-centered, dosage-centered approach to opioid taper to a patient-centered approach35 that emphasizes behavioral-medical integration—an approach that we broadly endorse. Such an approach (1) is based on a clear understanding of why the patient is taking opioid pain medication, (2) engages medical and complementary or alternative medicine specialists, (3) addresses underdiagnosis of psychological trauma, and (4) requires a quantum leap in access to trauma-specific behavioral health treatment resources. 36
Continue to: To underscore the case...
To underscore the case for shifting to a patient-centered approach35 we present sample cases in “How a patient-centered approach to tapering opioids looks in practice.”
SIDEBAR
How a patient-centered approach to tapering opioids looks in practice
Five hypothetical cases illustrate what might happen when a practice shifts from an addiction-centered, dosage-centered approach to one that places the individual at the center of care.
CASE #1: Brett F
Mr. F appears to use medication responsibly; benefits functionally from an opioid; has tolerable adverse effects; does not have significant psychosocial risk factors (based on the score of the Opioid Risk Tool [ORT] or the Screener and Opioid Assessment for Patients with Pain–Revised [SOAPP-R]); and is engaged in effective self-management. Most of Mr. F’s pain is thought to have a nociceptive or neuropathic source.
Mr F could reasonably contemplate continuing current opioid treatment.
Action: If the daily morphine milligram equivalent (MME) dosage is high, Mr. F should be referred to a pain medicine specialist. We recommend a periodic (at least annually) empiric trial of dosage reduction to see whether he is indeed best served by the current dosage.
CASE #2: Brett F (version 2.0)
Envision Mr. F having the same profile in all respects except that he is not engaged in effective self-management.
Optimal treatment of chronic pain often requires supplemental modalities beyond opioids.
Action: Physical therapy; an individualized, ongoing exercise regimen; interventional procedures; weight loss (if the patient is obese); smoking cessation; and improving coping skills for anxiety and depression without pharmacotherapy might not only temporarily alleviate the pain but, over time, improve Mr. F’s physical condition.
If Mr. F is not willing to do more than take the prescribed opioids, nothing is likely to change: Over time, his condition is likely to deteriorate. A patient like Mr. F can be harmed if opioids continue to be prescribed for him long-term.
Further action: If Mr. F won’t engage in broadening the approach to treating his pain, the opioid medication should be tapered, in his long-term best interest. A carrot-and-stick approach can facilitate Mr. F’s involvement in his care.
CASE #3: Clark S
Mr. S has a significant psychosocial component driving his pain: depression.a
Prescribing opioids without addressing the root cause of trauma is not in the patient’s best interest.
Action: Because of Mr. S’s depression, refer him to a behavioral health provider. If you determine that he is emotionally stable, wait until he is engaged in trauma treatment to begin the taper. If he appears unstable (eg, crying in the office, recent psychological stressors, recent impulsive behaviors, poor insight) consider (1) urgent behavioral health referral and (2) prescribing only enough opioid medication (ie, at close intervals) to prevent withdrawal and panic. Consider whether a psychotropic medication might be of benefit (eg, a serotonin–norepinephrine reuptake inhibitor or selective serotonin reuptake inhibitor).
Further action: Harm-reduction steps, such as close monitoring and, perhaps, a change to a buprenorphine product, is indicated, especially when the patient is overwhelmed by recent psychosocial stressors. Harm-reduction treatment is available through Medication-Assisted Therapy (MAT) programs; however, patients often run into difficulty obtaining access to these programs because regulations and laws restrict MAT to patients who have a diagnosis of opioid use disorder (OUD) and because some health plans and pharmacy benefit managers require prior authorization.
CASE #4: Gloria B
Ms. B isn’t managing her medications responsibly—although you don’t suspect OUD.
When a patient has shown the inability to manage opioid medication responsibly, you should delve into the reason to determine your next step.
Action: Evaluate Ms. B for a cognitive disorder or a thought disorder. Alternatively, as in the case of Mr. S, a psychosocial component might underlie her pain; in that case, the same recommendations can be made for her. In addition, you can propose that she identify a responsible person to dispense her medication.
CASE #5: Nicole L
You suspect that Ms. L, who is taking opioid medication to alleviate pain, also has a substance use disorder.
Action: Implement harm-reduction early for Ms. L: Obtain addiction medicine consultation and implement behavioral health strategies for addiction treatment.
A key characteristic of a substance use disorder is loss of control over use of the substance. A patient like Ms. L—who is in pain and who has an active OUD—cannot be expected to manage her opioid use responsibly.
Further action: We recommend that Ms. L be referred to an addiction specialist for MAT. Evidence of the harmreduction benefit of MAT is sufficient to strongly recommend it. Continue any other treatment modalities for pain that Ms. L has been using, such as non-opioid medication, physical therapy, alternative treatments, and behavioral therapy, or begin such treatments as appropriate.
a Depression is not the only psychosocial component that can underlie pain. Others include anxiety, posttraumatic stress disorder, and grief.
An eye toward the future. To inform future approaches to opioid tapering, more resources need to be deployed to
- support screening and risk stratification for PTSD, anxiety, and related disorders at the primary care level,
- continue the effort to identify and treat OUD,
- develop best-practice responses to screening, and
- make harm-reduction strategies that are now reserved for patients with OUD available to those who don't have OUD.
We urge that research be pursued into best practices for chronic pain interventions that target psychological trauma, anxiety, and depression.
CORRESPONDENCE
Bennet Davis MD, 2092 East Calle de Dulcinea, Tucson, AZ 85718; [email protected].
1. Centers for Disease Control and Prevention. Pocket guide: tapering for chronic pain. https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf. Accessed November 25, 2019.
2. Kral LA, Jackson K, Uritsky TJ. A practical guide to tapering opioids. Ment Health Clin. 2015;5:102-108.
3. Murphy L, Babaei-Rad R, Buna D, et al. Guidance on opioid tapering in the context of chronic pain: evidence, practical advice and frequently asked questions. Can Pharm J (Ott). 2018;151:114-120.
4. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc. 2005;90:828-842.
5. Davis M. Prescription opioid use among adults with mental health disorders in the United States. J Am Board Fam Med. 2017;30:407-417.
6. US Government Accountability Office. Report to Congressional Requestors. Prescription drug control: DEA has enhanced efforts to combat diversion, but could better assess and report program results. August 2011. www.gao.gov/assets/520/511464.pdf. Accessed November 25, 2019.
7. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Annual surveillance report of drug-related risks and outcomes. United States, 2017. www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Accessed November 25, 2019.
8. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999-2016, NCHS Data Brief No. 294. December 21, 2017. Hyattsville, MD: National Center for Health Statistics. www.cdc.gov/nchs/products/databriefs/db294.htm. Accessed November 25, 2019.
9. Overdose death rates. Bethesda, MD: National Institute on Drug Abuse. January 2019. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed November 25, 2019.
10. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999-2017. NCHS Data Brief No. 329. November 2018. Hyattsville, MD: National Center for Health Statistics. www.cdc.gov/nchs/data/databriefs/db329-h.pdf . Accessed November 25, 2019.
11. Manhapra A, Kertesz S, Oliva A, et al. VA data about Rx opioids and overdose and suicide: clinical implications. Presented at the 2018 National Rx Drug Abuse and Heroin Summit, Atlanta Georgia, April 4, 2018.
12. Demidenko M, Dobscha SK, Morasco BJ, et al. Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users. Gen Hosp Psychiatry. 2017;47:29-35.
13. Von Korff M, Walker RL, Saunders K, et al. Prevalence of prescription opioid use disorder among chronic opioid therapy patients after health plan opioid dose and risk reduction initiatives. Int J Drug Policy. 2017;46:90-98.
14. United States Food and Drug Administration. FDA Drug Safety Communication: FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. April 9, 2019. www.fda.gov/Drugs/DrugSafety/ucm635038.htm. Accessed November 25, 2019.
15. Becker W, Sullivan LE, Tetrault JM, et al. Non-medical use, abuse and dependence on prescription opioids among U.S. adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend. 2008;94:38-47.
16. Yovell Y, Bar G, Mashiah M, et al. Ultra-low-dose buprenorphine as a time-limited treatment for severe suicidal ideation: a randomized controlled trial. Am J Psychiatry. 2016;173:491-498.
17. Pradhan AA, Befort K, Nozaki C, et al. The delta opioid receptor: an evolving target for the treatment of brain disorders. Trends Pharmacol Sci. 2011;32:581-590.
18. Sugiyama A, Yamada M, Saitoh A, et al. Administration of a delta opioid receptor agonist KNT-127 to the basolateral amygdala has robust anxiolytic-like effects in rats. Psychopharmacology (Berl). 2018;235:2947-2955.
19. Richards EM, Mathews DC, Luckenbaugh DA, et al. A randomized, placebo-controlled pilot trial of the delta opioid receptor agonist AZD2327 in anxious depression. Psychopharmacology (Berl). 2016;233:1119-1130.
20. Yang PP, Yeh GC, Yeh TK, et al. Activation of delta-opioid receptor contributes to the antinociceptive effect of oxycodone in mice. Pharmacol Res. 2016;111:867-876.
21. America’s mental health 2018. Stamford, CT: Cohen Veterans Network. October 10, 2018. https://www.cohenveteransnetwork.org/wp-content/uploads/2018/10/Research-Summary-10-10-2018.pdf. Accessed November 25, 2019.
22. Classification of Chronic Pain, Second Edition (Revised). Washington, DC: International Association for the Study of Pain. Updated 2012. www.iasp-pain.org/PublicationsNews/Content.aspx?ItemNumber=1673. Accessed November 25, 2019.
23. Davis B, Vanderah TW. A new paradigm for pain? J Fam Pract. 2016 65:598-605.
24. Defrin R, Ginzburg K, Solomon Z, et al. Quantitative testing of pain perception in subjects with PTSD—implications for the mechanism of the coexistence between PTSD and chronic pain. Pain. 2008;138:450-459.
25. Foa EB, Gillihan SJ, Bryant RA. Challenges and successes in dissemination of evidence-based treatments for posttraumatic stress: lessons learned from prolonged exposure therapy for PTSD. Psychol Science Public Interest. 2013;14:65-111.
26. Miele D, O’Brien EJ. Underdiagnosis of posttraumatic stress disorder in at risk youth. J Trauma Stress. 2010;23:591-598.
27. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, DC: American Psychiatric Publishing; 2013:541.
28. Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372:241-248.
29. Schuchat A, Houry D, Guy GP Jr. New data on opioid use and prescribing in the United States. JAMA. 2017;318:425-426.
30. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. 2001. www.naabt.org/documents/APS_consensus_document.pdf. Accessed November 25, 2019.
31. Fishbain DA, Cole B, Lewis J, et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9:444-459.
32. Volkow ND, McClellan AT. Opioid abuse in chronic pain—misconceptions and mitigation strategies. N Engl J Med. 2016;374:1253-1263.
33. Treede RD, Rief W, Barke A. A classification of chronic pain for ICD-11. Pain. 2015;156:1003-1007.
34. Screening, brief intervention, and referral to treatment (SBIRT). Rockville, MD: Substance Abuse and Mental Health Services Administration. www.samhsa.gov/sbirt. Accessed November 25, 2019.
35. Schneider JP, Davis B. How well do you know your patient? Pract Pain Manag. 2017;17(2). www.practicalpainmanagement.com/resources/practice-management/how-well-do-you-know-your-patient. Accessed November 25, 2019.
36. Schneider JP. A patient-centered approach to the opioid overdose crisis. J Miss State Med Assoc. 2018;59:232-233.
Many Americans who are treated with prescription opioid analgesics would be better off with less opioid or none at all. To that end, published opioid prescribing guidelines do provide guidance on the mechanics of tapering patients off opioids1-4—but they have a major flaw: They do not adequately account for the fact that people who have a diagnosis of chronic pain are a heterogeneous group and require diagnosis-specific treatment planning. A patient-centered approach to opioid tapers must account for the reality that many people who are given a prescription for an opioid to treat pain have significant mental health conditions—for which opioids act as a psychotropic agent. An opioid taper must therefore address psychological trauma, in particular.5 (See “Tapering and harm-reduction strategies have failed.”6-14)
SIDEBAR
Tapering and harm-reduction strategies have failed
Efforts to address the rising number of overdose events that involve opioids began in earnest in 2010. In a 2011 Government Accountability Office report to Congress, the Drug Enforcement Agency reported that “the number of regulatory investigations (of medical providers who prescribed opioids) tripled between fiscal years 2009- 2010.”6
How has it gone since 2010? High-dosage prescribing of opioids has fallen by 48% since 2011, yet the decline has not reduced overdose events of any kind.7,8 Just the opposite: The 19,000 overdose deaths recorded in 2010 involving any opioid increased to 49,068 by 2017, the National Institute on Drug Abuse reports.9 The increase in opioid overdose deaths is fueled by a recent 9-fold increase in consumption of the synthetic opioid fentanyl: “The rate of drug overdose deaths involving synthetic opioids other than methadone … increased on average by 8% per year from 1999 through 2013 and by 71% per year from 2013 through 2017.”10
These and other statistics document only a modest rise in deaths that involve prescription opioids: from 15,000 in 2010 to 19,000 in 2016.9,10 Since 2010, the crisis of opioid overdose deaths burns hotter, and the pattern of opioid use has shifted from prescription drugs to much deadlier illicit drugs, such as heroin.
Interventions have not been successful overall. Results of research focused on the impact of opioid tapering and harm-reduction strategies implemented this decade are likewise discouraging. In 2018, the US Department of Veterans Affairs reported that opioid discontinuation was not associated with a reduction in overdose but was associated with an increase in suicide.11,12 Von Korff and colleagues, in a 2017 report, concluded that “Long-term implementation of opioid dose and risk reduction initiatives [in Washington state] was not associated with lower rates of prescription opioid use disorder among prevalent [chronic opioid therapy] patients.”13
Evidence suggests that efforts to address the opioid crisis of the past decade have had an effect that is the opposite of what was intended. The federal government recognized this in April 2019 in a Drug Safety Communication: “The US Food and Drug Administration (FDA) has received reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.”14
In this article, we present an evidence-based consensus approach to opioid tapering for your practice that is informed by a broader understanding of why patients take prescription opioids and why they, occasionally, switch to illicit drugs when their prescription is tapered. This consensus approach is based on the experience of the authors, members of the pain faculty of Project ECHO (Extension for Community Healthcare Outcomes) of the ECHO Institute, a worldwide initiative that uses adult learning techniques and interactive video technology to connect community providers with specialists at centers of excellence in regular real-time collaborative sessions. We are variously experts in pain medicine, primary care, psychology, addiction medicine, pharmacy, behavioral health therapy, occupational medicine, and Chinese medicine.
Why Americans obtain prescription opioids
There are 4 principal reasons why patients obtain prescription opioids, beyond indicated analgesic uses:
1. Patients seek the antianxiety and antidepressant effects of opioids. Multiple converging lines of evidence suggest that antianxiety and antidepressant effects of opioids are a significant reason that patients in the United States persist in requesting prescriptions for opioids:
- In our experience with more than 500 primary care telemedicine case presentations, at least 50% of patients say that the main effect of opioids prescribed for them is “it makes me feel calm” or “more relaxed.”
- In a 2007 survey of 91,823 US residents older than 18 years, nonmedical use of opioids was statistically associated with panic, social anxiety, and depressive symptoms.15
- Ten years later, Von Korff and colleagues found that more than half of opioid prescriptions written in the United States were for the small percentage of patients who have a diagnosis of serious anxiety or depression.13
- In 2016, Yovell and colleagues reported that ultra-low-dosage buprenorphine markedly reduced suicidal ideation over 4 weeks in 62 patients with varied levels of depression.16
There is also mechanistic evidence that the antianxiety and antidepressant effects of opioids are significant reasons Americans persist in requesting prescription opioids. The literature suggests that opioid receptors play a role in mood regulation, including alleviation of depression and anxiety; recent research suggests that oxycodone might be a unique mood-altering drug compared to other common prescription opioids because of its ability to affect mood through the δ opioid receptor.17-20
It should not be a surprise that Americans often turn to opioids to address posttraumatic stress disorder (PTSD), anxiety, and depression. A recent study of the state of the US mental health system concluded that mental health services in the United States are inadequate—despite evidence that > 50% of Americans seek, or consider seeking, treatment for mental health problems for themselves or others.21
2. Patients experience pain unrelated to tissue damage. Rather, they are in pain “for psychological reasons.”22 In 2016, Davis and Vanderah wrote: “We theorize that a functional change in the [central nervous system] can occur in response to certain emotional states or traumatic experiences (eg, child abuse, assault, accidents).” They connect this change to central sensitization and a reduced pain-perception threshold,23 and strongly suspect that many patients with chronic pain have undiagnosed and untreated psychological trauma that has changed the way their central nervous system processes sensory stimuli. The authors call this “trauma-induced hyperalgesia.”
Continue to: Psychological trauma...
Psychological trauma is uniquely capable of producing hyperalgesia, compared to anxiety or depression. In a study of veterans, Defrin and colleagues demonstrated hyperalgesia in patients who had a diagnosis of PTSD but not in controls group who had an anxiety disorder only.24
To support successful opioid tapering, trauma-induced hyperalgesia, when present, must be addressed. Treatment of what the International Association for the Study of Pain calls “pain due to psychological factors”22 requires specific trauma therapy. However, our experience validates what researchers have to say about access to treatment of psychological trauma in the United States: “…[C]linical research has identified certain psychological interventions that effectively ameliorate the symptoms of PTSD. But most people struggling with PTSD don’t receive those treatments.”25
We have no doubt that this is due, in part, to underdiagnosis of psychological trauma, even in mental health clinics. According to Miele and colleagues, “PTSD remains largely undiagnosed and undertreated in mental health outpatients, even in teaching hospitals, with diagnosis rates as low as 4% while published prevalence is between 7% and 50% in this population.”26
3. Patients suffer from opioid use disorder (OUD) and complain of pain to obtain opioids by prescription. For patients with OUD, their use is out of control; they devote increasing mental and physical resources to obtaining, using, and recovering from substances; and they continue to use despite adverse consequences.27 The prevalence of OUD in primary care clinics varies strikingly by the location of clinics. In Washington state, the prevalence of moderate and severe OUD in a large population of patients who had been prescribed opioids through primary care clinics was recently determined to be between 21.5% and 23.9%.13
4. Patients are obtaining opioid prescriptions for people other than themselves. While this is a reason that patients obtain opioid prescriptions, it is not necessarily common. Statistics show that the likelihood of a prescription being diverted intentionally is low: Dart and colleagues found that diversion has become uncommon in the general population.28
Continue to: Why we taper opioid analgesics
Why we taper opioid analgesics
Reasons for an opioid taper include concern that the patient has, or will develop, an OUD; will experience accidental or intentional overdose; might be diverting opioids; is not benefiting from opioid therapy for pain; or is experiencing severe adverse effects. A patient who has nociceptive pain and might have opioid-induced hyperalgesia will require a much different opioid taper plan than a patient with untreated PTSD or a patient with severe OUD.
Misunderstanding can lead to inappropriate tapering
We often encounter primary care providers who believe that a large percentage of patients on chronic opioid therapy inevitably develop OUD. This is a common reason for initiating opioid taper. Most patients on a chronic opioid do become physically dependent, but only a small percentage of patients develop psychological dependence (ie, addiction or OUD).29
Physical dependence is “a state of adaptation that is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.”30 Symptoms of opioid withdrawal include muscle aches; abdominal cramping; increased lacrimation, rhinorrhea, and perspiration; diarrhea; agitation and anxiety; insomnia; and piloerection. Opioid withdrawal symptoms are caused by physical dependence, not by addiction. They can be mitigated by tapering slowly and instituting adjuvant medications, such as clonidine, to attenuate symptoms.
Psychological dependence, or addiction (that is, OUD, as described in the Diagnostic and Statistical Manual of Mental Disorders 5th edition27), comprises primarily 3 behavioral criteria:
- Loss of control of the medication, with compulsive use
- Continued use despite adverse consequences of using opioids, such as arrest for driving under the influence and deterioration of social, family, or work performance
- Obsession or preoccupation with obtaining and using the substance. In properly selected chronic opioid therapy patients, there is evidence that new-onset OUD is not as common as has been thought. A recent study of the risk for opioid addiction after use of an opioid for ≥ 90 days for chronic noncancer pain found that the absolute rate of de novo OUD among patients treated for 90 days was 0.72%.29 A systematic review by Fishbain and colleagues of 24 studies of opioid-exposed patients found a risk of 3.27% overall—0.19% for patients who did not have a history of abuse or addiction.31 As Director of the National Institute on Drug Abuse Norma Volkow, MD, wrote in 2016: “Addiction occurs in only a small percentage of people who are exposed to opioids—even among those with preexisting vulnerabilities.”32
Assessment should focus on why the patient is taking an opioid
A strong case can be made that less opioid is better for many of the people for whom these medications are prescribed for chronic noncancer pain. However, a one-size-fits-all dosage reduction and addiction-focused approach to opioid tapering has not worked: The assessment and treatment paradigm must change, in our view.
Continue to: During assessment...
During assessment, we must adopt the means to identify the reason that a patient is using a prescription opioid. It is of particular importance that we identify patients using opioids for their psychotropic properties, particularly when the goal is to cope with the effects of psychological trauma. The subsequent treatment protocol will then need to include time for effective, evidence-based behavioral health treatment of anxiety, PTSD, or depression. If opioids are serving primarily as psychotropic medication, an attempt to taper before establishing effective behavioral health treatment might lead the patient to pursue illegal means of procuring opioid medication.
We acknowledge that primary care physicians are not reimbursed for trauma screening and that evidence-based intensive trauma treatment is generally unavailable in the United States. Both of these shortcomings must be corrected if we want to stem the opioid crisis.
If diversion is suspected and there is evidence that the patient is not currently taking prescribed opioids (eg, a negative urine drug screen), discontinuing the opioid prescription is the immediate next step for the sake of public safety.
SIDEBAR
2 decisions to make before continuing to prescribe an opioid for chronic noncancer pain
#1 Should I provide the patient with a prescription for an opioid for a few days, while I await more information?a
Yes. Writing a prescription is a reasonable decision if all of the following apply:
- You do not have significant suspicion of diversion (based on a clinical interview).
- You do not suspect an active addiction disorder, based on the score of the 10-question Drug Abuse Screening Test (DAST-10) and on a clinical interview. (DAST-10 is available at: https://cde.drugabuse.gov/instrument/e9053390-ee9c-9140-e040-bb89ad433d69.)
- The patient is likely to experience withdrawal symptoms if you don’t provide the medication immediately.
- The patient’s pain and function are likely to be impaired if you do not provide the medication.
- The patient does not display altered mental status during the visit (eg, drowsy, slurred speech).
No. If writing a prescription for an opioid for a few days does not seem to be a reasonable decision because the criteria above are not met, but withdrawal symptoms are likely, you can prescribe medication to mitigate symptoms or refer the patient for treatment of withdrawal.
#2 I’ve decided to provide the patient with a prescription for an opioid. For how many days should I write it?
The usual practice, for a patient whose case is familiar to you, is to prescribe a 1-month supply.
However, if any 1 of the following criteria is met, prescribing a 1-month supply is unsafe under most circumstances:
- An unstable social or living environment places the patient at risk by possessing a supply of opioids (based on a clinical interview).
- You suspect an unstable or severe behavioral health condition or a mental health diagnosis (based on a clinical interview or on the patient record from outside your practice).
- The patient scores as “high risk” on the Opioid Risk Tool (ORT; www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf), Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP-R; www.ncbi.nlm.nih.gov/pmc/articles/PMC4706778/), or a similar opioid risk assessment tool.
When 1 or more of these exclusionary criteria are met, you have 3 options:
- Prescribe an opioid for a brief duration and see the patient often.
- Do not prescribe an opioid; instead, refer the patient as necessary for treatment of withdrawal.
- Refer the patient for treatment of the underlying behavioral health condition.
a Additional information might include findings from consultants you’ve engaged regarding the patient’s diagnosis; a response to your call from a past prescriber; urine drug screen results; and results of a prescription monitoring program check.
Considering a taper? Take this 5-step approach
Once it appears that tapering an opioid is indicated, we propose that you take the following steps:
- Establish whether it is safe to continue prescribing (follow the route provided in “2 decisions to make before continuing to prescribe an opioid for chronic noncancer pain”); if continuing it is not safe, take steps to protect the patient and the community
- Determine whether assessment by a trauma-informed behavioral health expert is needed, assuming that, in your judgment, it is safe to continue the opioid (TABLE33). When behavioral health assessment is needed, you need 3 questions answered by that assessment: (1) Are psychological factors present that might put the patient at risk during an opioid taper? (2) What are those factors? (3) What needs to done about them before the taper is started? Recalling that psychological trauma often is not assessed by behavioral health colleagues, it is necessary to provide the behavioral health provider with a specific request to assess trauma burden, and state the physical diagnoses that are causing pain or provide a clear statement that no such diagnoses can be made. (See the FIGURE, which we developed in conjunction with behavioral health colleagues to help the consultant understand what the primary care physician needs from a behavioral health assessment.)
- Obtain consultation from a physical therapist, pain medicine specialist, and, if possible, an alternative or complementary medicine provider to determine what nonpharmacotherapeutic modalities can be instituted to treat pain before tapering the opioid.
- Initiate the Screening, Brief Intervention and Referral to Treatment (SBIRT) approach if OUD is suspected (www.samhsa.gov/sbirt).34 This motivational interviewing tool identifies patients with a substance use disorder, severity of use, and appropriate level of treatment. (If OUD is suspected during assessment, next steps are to stop prescribing and implement harm-reduction strategies, such as primary care level medically assisted treatment [MAT] with buprenorphine, followed by expert behavioral health-centered addiction treatment.)
- Experiment with dosage reduction according to published guidance, if (1) psychological factors are absent or have been adequately addressed, according to the behavioral health consultant, and (2) nonpharmacotherapeutic strategies are in place.8-11
Shifting to a patient-centered approach
The timing and choice of opioid tapers, in relation to harm reduction and intervention targeting the root cause of a patient’s complaint of pain, have not been adequately explored. In our practice, we’ve shifted from an addiction-centered, dosage-centered approach to opioid taper to a patient-centered approach35 that emphasizes behavioral-medical integration—an approach that we broadly endorse. Such an approach (1) is based on a clear understanding of why the patient is taking opioid pain medication, (2) engages medical and complementary or alternative medicine specialists, (3) addresses underdiagnosis of psychological trauma, and (4) requires a quantum leap in access to trauma-specific behavioral health treatment resources. 36
Continue to: To underscore the case...
To underscore the case for shifting to a patient-centered approach35 we present sample cases in “How a patient-centered approach to tapering opioids looks in practice.”
SIDEBAR
How a patient-centered approach to tapering opioids looks in practice
Five hypothetical cases illustrate what might happen when a practice shifts from an addiction-centered, dosage-centered approach to one that places the individual at the center of care.
CASE #1: Brett F
Mr. F appears to use medication responsibly; benefits functionally from an opioid; has tolerable adverse effects; does not have significant psychosocial risk factors (based on the score of the Opioid Risk Tool [ORT] or the Screener and Opioid Assessment for Patients with Pain–Revised [SOAPP-R]); and is engaged in effective self-management. Most of Mr. F’s pain is thought to have a nociceptive or neuropathic source.
Mr F could reasonably contemplate continuing current opioid treatment.
Action: If the daily morphine milligram equivalent (MME) dosage is high, Mr. F should be referred to a pain medicine specialist. We recommend a periodic (at least annually) empiric trial of dosage reduction to see whether he is indeed best served by the current dosage.
CASE #2: Brett F (version 2.0)
Envision Mr. F having the same profile in all respects except that he is not engaged in effective self-management.
Optimal treatment of chronic pain often requires supplemental modalities beyond opioids.
Action: Physical therapy; an individualized, ongoing exercise regimen; interventional procedures; weight loss (if the patient is obese); smoking cessation; and improving coping skills for anxiety and depression without pharmacotherapy might not only temporarily alleviate the pain but, over time, improve Mr. F’s physical condition.
If Mr. F is not willing to do more than take the prescribed opioids, nothing is likely to change: Over time, his condition is likely to deteriorate. A patient like Mr. F can be harmed if opioids continue to be prescribed for him long-term.
Further action: If Mr. F won’t engage in broadening the approach to treating his pain, the opioid medication should be tapered, in his long-term best interest. A carrot-and-stick approach can facilitate Mr. F’s involvement in his care.
CASE #3: Clark S
Mr. S has a significant psychosocial component driving his pain: depression.a
Prescribing opioids without addressing the root cause of trauma is not in the patient’s best interest.
Action: Because of Mr. S’s depression, refer him to a behavioral health provider. If you determine that he is emotionally stable, wait until he is engaged in trauma treatment to begin the taper. If he appears unstable (eg, crying in the office, recent psychological stressors, recent impulsive behaviors, poor insight) consider (1) urgent behavioral health referral and (2) prescribing only enough opioid medication (ie, at close intervals) to prevent withdrawal and panic. Consider whether a psychotropic medication might be of benefit (eg, a serotonin–norepinephrine reuptake inhibitor or selective serotonin reuptake inhibitor).
Further action: Harm-reduction steps, such as close monitoring and, perhaps, a change to a buprenorphine product, is indicated, especially when the patient is overwhelmed by recent psychosocial stressors. Harm-reduction treatment is available through Medication-Assisted Therapy (MAT) programs; however, patients often run into difficulty obtaining access to these programs because regulations and laws restrict MAT to patients who have a diagnosis of opioid use disorder (OUD) and because some health plans and pharmacy benefit managers require prior authorization.
CASE #4: Gloria B
Ms. B isn’t managing her medications responsibly—although you don’t suspect OUD.
When a patient has shown the inability to manage opioid medication responsibly, you should delve into the reason to determine your next step.
Action: Evaluate Ms. B for a cognitive disorder or a thought disorder. Alternatively, as in the case of Mr. S, a psychosocial component might underlie her pain; in that case, the same recommendations can be made for her. In addition, you can propose that she identify a responsible person to dispense her medication.
CASE #5: Nicole L
You suspect that Ms. L, who is taking opioid medication to alleviate pain, also has a substance use disorder.
Action: Implement harm-reduction early for Ms. L: Obtain addiction medicine consultation and implement behavioral health strategies for addiction treatment.
A key characteristic of a substance use disorder is loss of control over use of the substance. A patient like Ms. L—who is in pain and who has an active OUD—cannot be expected to manage her opioid use responsibly.
Further action: We recommend that Ms. L be referred to an addiction specialist for MAT. Evidence of the harmreduction benefit of MAT is sufficient to strongly recommend it. Continue any other treatment modalities for pain that Ms. L has been using, such as non-opioid medication, physical therapy, alternative treatments, and behavioral therapy, or begin such treatments as appropriate.
a Depression is not the only psychosocial component that can underlie pain. Others include anxiety, posttraumatic stress disorder, and grief.
An eye toward the future. To inform future approaches to opioid tapering, more resources need to be deployed to
- support screening and risk stratification for PTSD, anxiety, and related disorders at the primary care level,
- continue the effort to identify and treat OUD,
- develop best-practice responses to screening, and
- make harm-reduction strategies that are now reserved for patients with OUD available to those who don't have OUD.
We urge that research be pursued into best practices for chronic pain interventions that target psychological trauma, anxiety, and depression.
CORRESPONDENCE
Bennet Davis MD, 2092 East Calle de Dulcinea, Tucson, AZ 85718; [email protected].
Many Americans who are treated with prescription opioid analgesics would be better off with less opioid or none at all. To that end, published opioid prescribing guidelines do provide guidance on the mechanics of tapering patients off opioids1-4—but they have a major flaw: They do not adequately account for the fact that people who have a diagnosis of chronic pain are a heterogeneous group and require diagnosis-specific treatment planning. A patient-centered approach to opioid tapers must account for the reality that many people who are given a prescription for an opioid to treat pain have significant mental health conditions—for which opioids act as a psychotropic agent. An opioid taper must therefore address psychological trauma, in particular.5 (See “Tapering and harm-reduction strategies have failed.”6-14)
SIDEBAR
Tapering and harm-reduction strategies have failed
Efforts to address the rising number of overdose events that involve opioids began in earnest in 2010. In a 2011 Government Accountability Office report to Congress, the Drug Enforcement Agency reported that “the number of regulatory investigations (of medical providers who prescribed opioids) tripled between fiscal years 2009- 2010.”6
How has it gone since 2010? High-dosage prescribing of opioids has fallen by 48% since 2011, yet the decline has not reduced overdose events of any kind.7,8 Just the opposite: The 19,000 overdose deaths recorded in 2010 involving any opioid increased to 49,068 by 2017, the National Institute on Drug Abuse reports.9 The increase in opioid overdose deaths is fueled by a recent 9-fold increase in consumption of the synthetic opioid fentanyl: “The rate of drug overdose deaths involving synthetic opioids other than methadone … increased on average by 8% per year from 1999 through 2013 and by 71% per year from 2013 through 2017.”10
These and other statistics document only a modest rise in deaths that involve prescription opioids: from 15,000 in 2010 to 19,000 in 2016.9,10 Since 2010, the crisis of opioid overdose deaths burns hotter, and the pattern of opioid use has shifted from prescription drugs to much deadlier illicit drugs, such as heroin.
Interventions have not been successful overall. Results of research focused on the impact of opioid tapering and harm-reduction strategies implemented this decade are likewise discouraging. In 2018, the US Department of Veterans Affairs reported that opioid discontinuation was not associated with a reduction in overdose but was associated with an increase in suicide.11,12 Von Korff and colleagues, in a 2017 report, concluded that “Long-term implementation of opioid dose and risk reduction initiatives [in Washington state] was not associated with lower rates of prescription opioid use disorder among prevalent [chronic opioid therapy] patients.”13
Evidence suggests that efforts to address the opioid crisis of the past decade have had an effect that is the opposite of what was intended. The federal government recognized this in April 2019 in a Drug Safety Communication: “The US Food and Drug Administration (FDA) has received reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.”14
In this article, we present an evidence-based consensus approach to opioid tapering for your practice that is informed by a broader understanding of why patients take prescription opioids and why they, occasionally, switch to illicit drugs when their prescription is tapered. This consensus approach is based on the experience of the authors, members of the pain faculty of Project ECHO (Extension for Community Healthcare Outcomes) of the ECHO Institute, a worldwide initiative that uses adult learning techniques and interactive video technology to connect community providers with specialists at centers of excellence in regular real-time collaborative sessions. We are variously experts in pain medicine, primary care, psychology, addiction medicine, pharmacy, behavioral health therapy, occupational medicine, and Chinese medicine.
Why Americans obtain prescription opioids
There are 4 principal reasons why patients obtain prescription opioids, beyond indicated analgesic uses:
1. Patients seek the antianxiety and antidepressant effects of opioids. Multiple converging lines of evidence suggest that antianxiety and antidepressant effects of opioids are a significant reason that patients in the United States persist in requesting prescriptions for opioids:
- In our experience with more than 500 primary care telemedicine case presentations, at least 50% of patients say that the main effect of opioids prescribed for them is “it makes me feel calm” or “more relaxed.”
- In a 2007 survey of 91,823 US residents older than 18 years, nonmedical use of opioids was statistically associated with panic, social anxiety, and depressive symptoms.15
- Ten years later, Von Korff and colleagues found that more than half of opioid prescriptions written in the United States were for the small percentage of patients who have a diagnosis of serious anxiety or depression.13
- In 2016, Yovell and colleagues reported that ultra-low-dosage buprenorphine markedly reduced suicidal ideation over 4 weeks in 62 patients with varied levels of depression.16
There is also mechanistic evidence that the antianxiety and antidepressant effects of opioids are significant reasons Americans persist in requesting prescription opioids. The literature suggests that opioid receptors play a role in mood regulation, including alleviation of depression and anxiety; recent research suggests that oxycodone might be a unique mood-altering drug compared to other common prescription opioids because of its ability to affect mood through the δ opioid receptor.17-20
It should not be a surprise that Americans often turn to opioids to address posttraumatic stress disorder (PTSD), anxiety, and depression. A recent study of the state of the US mental health system concluded that mental health services in the United States are inadequate—despite evidence that > 50% of Americans seek, or consider seeking, treatment for mental health problems for themselves or others.21
2. Patients experience pain unrelated to tissue damage. Rather, they are in pain “for psychological reasons.”22 In 2016, Davis and Vanderah wrote: “We theorize that a functional change in the [central nervous system] can occur in response to certain emotional states or traumatic experiences (eg, child abuse, assault, accidents).” They connect this change to central sensitization and a reduced pain-perception threshold,23 and strongly suspect that many patients with chronic pain have undiagnosed and untreated psychological trauma that has changed the way their central nervous system processes sensory stimuli. The authors call this “trauma-induced hyperalgesia.”
Continue to: Psychological trauma...
Psychological trauma is uniquely capable of producing hyperalgesia, compared to anxiety or depression. In a study of veterans, Defrin and colleagues demonstrated hyperalgesia in patients who had a diagnosis of PTSD but not in controls group who had an anxiety disorder only.24
To support successful opioid tapering, trauma-induced hyperalgesia, when present, must be addressed. Treatment of what the International Association for the Study of Pain calls “pain due to psychological factors”22 requires specific trauma therapy. However, our experience validates what researchers have to say about access to treatment of psychological trauma in the United States: “…[C]linical research has identified certain psychological interventions that effectively ameliorate the symptoms of PTSD. But most people struggling with PTSD don’t receive those treatments.”25
We have no doubt that this is due, in part, to underdiagnosis of psychological trauma, even in mental health clinics. According to Miele and colleagues, “PTSD remains largely undiagnosed and undertreated in mental health outpatients, even in teaching hospitals, with diagnosis rates as low as 4% while published prevalence is between 7% and 50% in this population.”26
3. Patients suffer from opioid use disorder (OUD) and complain of pain to obtain opioids by prescription. For patients with OUD, their use is out of control; they devote increasing mental and physical resources to obtaining, using, and recovering from substances; and they continue to use despite adverse consequences.27 The prevalence of OUD in primary care clinics varies strikingly by the location of clinics. In Washington state, the prevalence of moderate and severe OUD in a large population of patients who had been prescribed opioids through primary care clinics was recently determined to be between 21.5% and 23.9%.13
4. Patients are obtaining opioid prescriptions for people other than themselves. While this is a reason that patients obtain opioid prescriptions, it is not necessarily common. Statistics show that the likelihood of a prescription being diverted intentionally is low: Dart and colleagues found that diversion has become uncommon in the general population.28
Continue to: Why we taper opioid analgesics
Why we taper opioid analgesics
Reasons for an opioid taper include concern that the patient has, or will develop, an OUD; will experience accidental or intentional overdose; might be diverting opioids; is not benefiting from opioid therapy for pain; or is experiencing severe adverse effects. A patient who has nociceptive pain and might have opioid-induced hyperalgesia will require a much different opioid taper plan than a patient with untreated PTSD or a patient with severe OUD.
Misunderstanding can lead to inappropriate tapering
We often encounter primary care providers who believe that a large percentage of patients on chronic opioid therapy inevitably develop OUD. This is a common reason for initiating opioid taper. Most patients on a chronic opioid do become physically dependent, but only a small percentage of patients develop psychological dependence (ie, addiction or OUD).29
Physical dependence is “a state of adaptation that is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.”30 Symptoms of opioid withdrawal include muscle aches; abdominal cramping; increased lacrimation, rhinorrhea, and perspiration; diarrhea; agitation and anxiety; insomnia; and piloerection. Opioid withdrawal symptoms are caused by physical dependence, not by addiction. They can be mitigated by tapering slowly and instituting adjuvant medications, such as clonidine, to attenuate symptoms.
Psychological dependence, or addiction (that is, OUD, as described in the Diagnostic and Statistical Manual of Mental Disorders 5th edition27), comprises primarily 3 behavioral criteria:
- Loss of control of the medication, with compulsive use
- Continued use despite adverse consequences of using opioids, such as arrest for driving under the influence and deterioration of social, family, or work performance
- Obsession or preoccupation with obtaining and using the substance. In properly selected chronic opioid therapy patients, there is evidence that new-onset OUD is not as common as has been thought. A recent study of the risk for opioid addiction after use of an opioid for ≥ 90 days for chronic noncancer pain found that the absolute rate of de novo OUD among patients treated for 90 days was 0.72%.29 A systematic review by Fishbain and colleagues of 24 studies of opioid-exposed patients found a risk of 3.27% overall—0.19% for patients who did not have a history of abuse or addiction.31 As Director of the National Institute on Drug Abuse Norma Volkow, MD, wrote in 2016: “Addiction occurs in only a small percentage of people who are exposed to opioids—even among those with preexisting vulnerabilities.”32
Assessment should focus on why the patient is taking an opioid
A strong case can be made that less opioid is better for many of the people for whom these medications are prescribed for chronic noncancer pain. However, a one-size-fits-all dosage reduction and addiction-focused approach to opioid tapering has not worked: The assessment and treatment paradigm must change, in our view.
Continue to: During assessment...
During assessment, we must adopt the means to identify the reason that a patient is using a prescription opioid. It is of particular importance that we identify patients using opioids for their psychotropic properties, particularly when the goal is to cope with the effects of psychological trauma. The subsequent treatment protocol will then need to include time for effective, evidence-based behavioral health treatment of anxiety, PTSD, or depression. If opioids are serving primarily as psychotropic medication, an attempt to taper before establishing effective behavioral health treatment might lead the patient to pursue illegal means of procuring opioid medication.
We acknowledge that primary care physicians are not reimbursed for trauma screening and that evidence-based intensive trauma treatment is generally unavailable in the United States. Both of these shortcomings must be corrected if we want to stem the opioid crisis.
If diversion is suspected and there is evidence that the patient is not currently taking prescribed opioids (eg, a negative urine drug screen), discontinuing the opioid prescription is the immediate next step for the sake of public safety.
SIDEBAR
2 decisions to make before continuing to prescribe an opioid for chronic noncancer pain
#1 Should I provide the patient with a prescription for an opioid for a few days, while I await more information?a
Yes. Writing a prescription is a reasonable decision if all of the following apply:
- You do not have significant suspicion of diversion (based on a clinical interview).
- You do not suspect an active addiction disorder, based on the score of the 10-question Drug Abuse Screening Test (DAST-10) and on a clinical interview. (DAST-10 is available at: https://cde.drugabuse.gov/instrument/e9053390-ee9c-9140-e040-bb89ad433d69.)
- The patient is likely to experience withdrawal symptoms if you don’t provide the medication immediately.
- The patient’s pain and function are likely to be impaired if you do not provide the medication.
- The patient does not display altered mental status during the visit (eg, drowsy, slurred speech).
No. If writing a prescription for an opioid for a few days does not seem to be a reasonable decision because the criteria above are not met, but withdrawal symptoms are likely, you can prescribe medication to mitigate symptoms or refer the patient for treatment of withdrawal.
#2 I’ve decided to provide the patient with a prescription for an opioid. For how many days should I write it?
The usual practice, for a patient whose case is familiar to you, is to prescribe a 1-month supply.
However, if any 1 of the following criteria is met, prescribing a 1-month supply is unsafe under most circumstances:
- An unstable social or living environment places the patient at risk by possessing a supply of opioids (based on a clinical interview).
- You suspect an unstable or severe behavioral health condition or a mental health diagnosis (based on a clinical interview or on the patient record from outside your practice).
- The patient scores as “high risk” on the Opioid Risk Tool (ORT; www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf), Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP-R; www.ncbi.nlm.nih.gov/pmc/articles/PMC4706778/), or a similar opioid risk assessment tool.
When 1 or more of these exclusionary criteria are met, you have 3 options:
- Prescribe an opioid for a brief duration and see the patient often.
- Do not prescribe an opioid; instead, refer the patient as necessary for treatment of withdrawal.
- Refer the patient for treatment of the underlying behavioral health condition.
a Additional information might include findings from consultants you’ve engaged regarding the patient’s diagnosis; a response to your call from a past prescriber; urine drug screen results; and results of a prescription monitoring program check.
Considering a taper? Take this 5-step approach
Once it appears that tapering an opioid is indicated, we propose that you take the following steps:
- Establish whether it is safe to continue prescribing (follow the route provided in “2 decisions to make before continuing to prescribe an opioid for chronic noncancer pain”); if continuing it is not safe, take steps to protect the patient and the community
- Determine whether assessment by a trauma-informed behavioral health expert is needed, assuming that, in your judgment, it is safe to continue the opioid (TABLE33). When behavioral health assessment is needed, you need 3 questions answered by that assessment: (1) Are psychological factors present that might put the patient at risk during an opioid taper? (2) What are those factors? (3) What needs to done about them before the taper is started? Recalling that psychological trauma often is not assessed by behavioral health colleagues, it is necessary to provide the behavioral health provider with a specific request to assess trauma burden, and state the physical diagnoses that are causing pain or provide a clear statement that no such diagnoses can be made. (See the FIGURE, which we developed in conjunction with behavioral health colleagues to help the consultant understand what the primary care physician needs from a behavioral health assessment.)
- Obtain consultation from a physical therapist, pain medicine specialist, and, if possible, an alternative or complementary medicine provider to determine what nonpharmacotherapeutic modalities can be instituted to treat pain before tapering the opioid.
- Initiate the Screening, Brief Intervention and Referral to Treatment (SBIRT) approach if OUD is suspected (www.samhsa.gov/sbirt).34 This motivational interviewing tool identifies patients with a substance use disorder, severity of use, and appropriate level of treatment. (If OUD is suspected during assessment, next steps are to stop prescribing and implement harm-reduction strategies, such as primary care level medically assisted treatment [MAT] with buprenorphine, followed by expert behavioral health-centered addiction treatment.)
- Experiment with dosage reduction according to published guidance, if (1) psychological factors are absent or have been adequately addressed, according to the behavioral health consultant, and (2) nonpharmacotherapeutic strategies are in place.8-11
Shifting to a patient-centered approach
The timing and choice of opioid tapers, in relation to harm reduction and intervention targeting the root cause of a patient’s complaint of pain, have not been adequately explored. In our practice, we’ve shifted from an addiction-centered, dosage-centered approach to opioid taper to a patient-centered approach35 that emphasizes behavioral-medical integration—an approach that we broadly endorse. Such an approach (1) is based on a clear understanding of why the patient is taking opioid pain medication, (2) engages medical and complementary or alternative medicine specialists, (3) addresses underdiagnosis of psychological trauma, and (4) requires a quantum leap in access to trauma-specific behavioral health treatment resources. 36
Continue to: To underscore the case...
To underscore the case for shifting to a patient-centered approach35 we present sample cases in “How a patient-centered approach to tapering opioids looks in practice.”
SIDEBAR
How a patient-centered approach to tapering opioids looks in practice
Five hypothetical cases illustrate what might happen when a practice shifts from an addiction-centered, dosage-centered approach to one that places the individual at the center of care.
CASE #1: Brett F
Mr. F appears to use medication responsibly; benefits functionally from an opioid; has tolerable adverse effects; does not have significant psychosocial risk factors (based on the score of the Opioid Risk Tool [ORT] or the Screener and Opioid Assessment for Patients with Pain–Revised [SOAPP-R]); and is engaged in effective self-management. Most of Mr. F’s pain is thought to have a nociceptive or neuropathic source.
Mr F could reasonably contemplate continuing current opioid treatment.
Action: If the daily morphine milligram equivalent (MME) dosage is high, Mr. F should be referred to a pain medicine specialist. We recommend a periodic (at least annually) empiric trial of dosage reduction to see whether he is indeed best served by the current dosage.
CASE #2: Brett F (version 2.0)
Envision Mr. F having the same profile in all respects except that he is not engaged in effective self-management.
Optimal treatment of chronic pain often requires supplemental modalities beyond opioids.
Action: Physical therapy; an individualized, ongoing exercise regimen; interventional procedures; weight loss (if the patient is obese); smoking cessation; and improving coping skills for anxiety and depression without pharmacotherapy might not only temporarily alleviate the pain but, over time, improve Mr. F’s physical condition.
If Mr. F is not willing to do more than take the prescribed opioids, nothing is likely to change: Over time, his condition is likely to deteriorate. A patient like Mr. F can be harmed if opioids continue to be prescribed for him long-term.
Further action: If Mr. F won’t engage in broadening the approach to treating his pain, the opioid medication should be tapered, in his long-term best interest. A carrot-and-stick approach can facilitate Mr. F’s involvement in his care.
CASE #3: Clark S
Mr. S has a significant psychosocial component driving his pain: depression.a
Prescribing opioids without addressing the root cause of trauma is not in the patient’s best interest.
Action: Because of Mr. S’s depression, refer him to a behavioral health provider. If you determine that he is emotionally stable, wait until he is engaged in trauma treatment to begin the taper. If he appears unstable (eg, crying in the office, recent psychological stressors, recent impulsive behaviors, poor insight) consider (1) urgent behavioral health referral and (2) prescribing only enough opioid medication (ie, at close intervals) to prevent withdrawal and panic. Consider whether a psychotropic medication might be of benefit (eg, a serotonin–norepinephrine reuptake inhibitor or selective serotonin reuptake inhibitor).
Further action: Harm-reduction steps, such as close monitoring and, perhaps, a change to a buprenorphine product, is indicated, especially when the patient is overwhelmed by recent psychosocial stressors. Harm-reduction treatment is available through Medication-Assisted Therapy (MAT) programs; however, patients often run into difficulty obtaining access to these programs because regulations and laws restrict MAT to patients who have a diagnosis of opioid use disorder (OUD) and because some health plans and pharmacy benefit managers require prior authorization.
CASE #4: Gloria B
Ms. B isn’t managing her medications responsibly—although you don’t suspect OUD.
When a patient has shown the inability to manage opioid medication responsibly, you should delve into the reason to determine your next step.
Action: Evaluate Ms. B for a cognitive disorder or a thought disorder. Alternatively, as in the case of Mr. S, a psychosocial component might underlie her pain; in that case, the same recommendations can be made for her. In addition, you can propose that she identify a responsible person to dispense her medication.
CASE #5: Nicole L
You suspect that Ms. L, who is taking opioid medication to alleviate pain, also has a substance use disorder.
Action: Implement harm-reduction early for Ms. L: Obtain addiction medicine consultation and implement behavioral health strategies for addiction treatment.
A key characteristic of a substance use disorder is loss of control over use of the substance. A patient like Ms. L—who is in pain and who has an active OUD—cannot be expected to manage her opioid use responsibly.
Further action: We recommend that Ms. L be referred to an addiction specialist for MAT. Evidence of the harmreduction benefit of MAT is sufficient to strongly recommend it. Continue any other treatment modalities for pain that Ms. L has been using, such as non-opioid medication, physical therapy, alternative treatments, and behavioral therapy, or begin such treatments as appropriate.
a Depression is not the only psychosocial component that can underlie pain. Others include anxiety, posttraumatic stress disorder, and grief.
An eye toward the future. To inform future approaches to opioid tapering, more resources need to be deployed to
- support screening and risk stratification for PTSD, anxiety, and related disorders at the primary care level,
- continue the effort to identify and treat OUD,
- develop best-practice responses to screening, and
- make harm-reduction strategies that are now reserved for patients with OUD available to those who don't have OUD.
We urge that research be pursued into best practices for chronic pain interventions that target psychological trauma, anxiety, and depression.
CORRESPONDENCE
Bennet Davis MD, 2092 East Calle de Dulcinea, Tucson, AZ 85718; [email protected].
1. Centers for Disease Control and Prevention. Pocket guide: tapering for chronic pain. https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf. Accessed November 25, 2019.
2. Kral LA, Jackson K, Uritsky TJ. A practical guide to tapering opioids. Ment Health Clin. 2015;5:102-108.
3. Murphy L, Babaei-Rad R, Buna D, et al. Guidance on opioid tapering in the context of chronic pain: evidence, practical advice and frequently asked questions. Can Pharm J (Ott). 2018;151:114-120.
4. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc. 2005;90:828-842.
5. Davis M. Prescription opioid use among adults with mental health disorders in the United States. J Am Board Fam Med. 2017;30:407-417.
6. US Government Accountability Office. Report to Congressional Requestors. Prescription drug control: DEA has enhanced efforts to combat diversion, but could better assess and report program results. August 2011. www.gao.gov/assets/520/511464.pdf. Accessed November 25, 2019.
7. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Annual surveillance report of drug-related risks and outcomes. United States, 2017. www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Accessed November 25, 2019.
8. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999-2016, NCHS Data Brief No. 294. December 21, 2017. Hyattsville, MD: National Center for Health Statistics. www.cdc.gov/nchs/products/databriefs/db294.htm. Accessed November 25, 2019.
9. Overdose death rates. Bethesda, MD: National Institute on Drug Abuse. January 2019. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed November 25, 2019.
10. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999-2017. NCHS Data Brief No. 329. November 2018. Hyattsville, MD: National Center for Health Statistics. www.cdc.gov/nchs/data/databriefs/db329-h.pdf . Accessed November 25, 2019.
11. Manhapra A, Kertesz S, Oliva A, et al. VA data about Rx opioids and overdose and suicide: clinical implications. Presented at the 2018 National Rx Drug Abuse and Heroin Summit, Atlanta Georgia, April 4, 2018.
12. Demidenko M, Dobscha SK, Morasco BJ, et al. Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users. Gen Hosp Psychiatry. 2017;47:29-35.
13. Von Korff M, Walker RL, Saunders K, et al. Prevalence of prescription opioid use disorder among chronic opioid therapy patients after health plan opioid dose and risk reduction initiatives. Int J Drug Policy. 2017;46:90-98.
14. United States Food and Drug Administration. FDA Drug Safety Communication: FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. April 9, 2019. www.fda.gov/Drugs/DrugSafety/ucm635038.htm. Accessed November 25, 2019.
15. Becker W, Sullivan LE, Tetrault JM, et al. Non-medical use, abuse and dependence on prescription opioids among U.S. adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend. 2008;94:38-47.
16. Yovell Y, Bar G, Mashiah M, et al. Ultra-low-dose buprenorphine as a time-limited treatment for severe suicidal ideation: a randomized controlled trial. Am J Psychiatry. 2016;173:491-498.
17. Pradhan AA, Befort K, Nozaki C, et al. The delta opioid receptor: an evolving target for the treatment of brain disorders. Trends Pharmacol Sci. 2011;32:581-590.
18. Sugiyama A, Yamada M, Saitoh A, et al. Administration of a delta opioid receptor agonist KNT-127 to the basolateral amygdala has robust anxiolytic-like effects in rats. Psychopharmacology (Berl). 2018;235:2947-2955.
19. Richards EM, Mathews DC, Luckenbaugh DA, et al. A randomized, placebo-controlled pilot trial of the delta opioid receptor agonist AZD2327 in anxious depression. Psychopharmacology (Berl). 2016;233:1119-1130.
20. Yang PP, Yeh GC, Yeh TK, et al. Activation of delta-opioid receptor contributes to the antinociceptive effect of oxycodone in mice. Pharmacol Res. 2016;111:867-876.
21. America’s mental health 2018. Stamford, CT: Cohen Veterans Network. October 10, 2018. https://www.cohenveteransnetwork.org/wp-content/uploads/2018/10/Research-Summary-10-10-2018.pdf. Accessed November 25, 2019.
22. Classification of Chronic Pain, Second Edition (Revised). Washington, DC: International Association for the Study of Pain. Updated 2012. www.iasp-pain.org/PublicationsNews/Content.aspx?ItemNumber=1673. Accessed November 25, 2019.
23. Davis B, Vanderah TW. A new paradigm for pain? J Fam Pract. 2016 65:598-605.
24. Defrin R, Ginzburg K, Solomon Z, et al. Quantitative testing of pain perception in subjects with PTSD—implications for the mechanism of the coexistence between PTSD and chronic pain. Pain. 2008;138:450-459.
25. Foa EB, Gillihan SJ, Bryant RA. Challenges and successes in dissemination of evidence-based treatments for posttraumatic stress: lessons learned from prolonged exposure therapy for PTSD. Psychol Science Public Interest. 2013;14:65-111.
26. Miele D, O’Brien EJ. Underdiagnosis of posttraumatic stress disorder in at risk youth. J Trauma Stress. 2010;23:591-598.
27. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, DC: American Psychiatric Publishing; 2013:541.
28. Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372:241-248.
29. Schuchat A, Houry D, Guy GP Jr. New data on opioid use and prescribing in the United States. JAMA. 2017;318:425-426.
30. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. 2001. www.naabt.org/documents/APS_consensus_document.pdf. Accessed November 25, 2019.
31. Fishbain DA, Cole B, Lewis J, et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9:444-459.
32. Volkow ND, McClellan AT. Opioid abuse in chronic pain—misconceptions and mitigation strategies. N Engl J Med. 2016;374:1253-1263.
33. Treede RD, Rief W, Barke A. A classification of chronic pain for ICD-11. Pain. 2015;156:1003-1007.
34. Screening, brief intervention, and referral to treatment (SBIRT). Rockville, MD: Substance Abuse and Mental Health Services Administration. www.samhsa.gov/sbirt. Accessed November 25, 2019.
35. Schneider JP, Davis B. How well do you know your patient? Pract Pain Manag. 2017;17(2). www.practicalpainmanagement.com/resources/practice-management/how-well-do-you-know-your-patient. Accessed November 25, 2019.
36. Schneider JP. A patient-centered approach to the opioid overdose crisis. J Miss State Med Assoc. 2018;59:232-233.
1. Centers for Disease Control and Prevention. Pocket guide: tapering for chronic pain. https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf. Accessed November 25, 2019.
2. Kral LA, Jackson K, Uritsky TJ. A practical guide to tapering opioids. Ment Health Clin. 2015;5:102-108.
3. Murphy L, Babaei-Rad R, Buna D, et al. Guidance on opioid tapering in the context of chronic pain: evidence, practical advice and frequently asked questions. Can Pharm J (Ott). 2018;151:114-120.
4. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc. 2005;90:828-842.
5. Davis M. Prescription opioid use among adults with mental health disorders in the United States. J Am Board Fam Med. 2017;30:407-417.
6. US Government Accountability Office. Report to Congressional Requestors. Prescription drug control: DEA has enhanced efforts to combat diversion, but could better assess and report program results. August 2011. www.gao.gov/assets/520/511464.pdf. Accessed November 25, 2019.
7. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Annual surveillance report of drug-related risks and outcomes. United States, 2017. www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Accessed November 25, 2019.
8. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999-2016, NCHS Data Brief No. 294. December 21, 2017. Hyattsville, MD: National Center for Health Statistics. www.cdc.gov/nchs/products/databriefs/db294.htm. Accessed November 25, 2019.
9. Overdose death rates. Bethesda, MD: National Institute on Drug Abuse. January 2019. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed November 25, 2019.
10. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999-2017. NCHS Data Brief No. 329. November 2018. Hyattsville, MD: National Center for Health Statistics. www.cdc.gov/nchs/data/databriefs/db329-h.pdf . Accessed November 25, 2019.
11. Manhapra A, Kertesz S, Oliva A, et al. VA data about Rx opioids and overdose and suicide: clinical implications. Presented at the 2018 National Rx Drug Abuse and Heroin Summit, Atlanta Georgia, April 4, 2018.
12. Demidenko M, Dobscha SK, Morasco BJ, et al. Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users. Gen Hosp Psychiatry. 2017;47:29-35.
13. Von Korff M, Walker RL, Saunders K, et al. Prevalence of prescription opioid use disorder among chronic opioid therapy patients after health plan opioid dose and risk reduction initiatives. Int J Drug Policy. 2017;46:90-98.
14. United States Food and Drug Administration. FDA Drug Safety Communication: FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. April 9, 2019. www.fda.gov/Drugs/DrugSafety/ucm635038.htm. Accessed November 25, 2019.
15. Becker W, Sullivan LE, Tetrault JM, et al. Non-medical use, abuse and dependence on prescription opioids among U.S. adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend. 2008;94:38-47.
16. Yovell Y, Bar G, Mashiah M, et al. Ultra-low-dose buprenorphine as a time-limited treatment for severe suicidal ideation: a randomized controlled trial. Am J Psychiatry. 2016;173:491-498.
17. Pradhan AA, Befort K, Nozaki C, et al. The delta opioid receptor: an evolving target for the treatment of brain disorders. Trends Pharmacol Sci. 2011;32:581-590.
18. Sugiyama A, Yamada M, Saitoh A, et al. Administration of a delta opioid receptor agonist KNT-127 to the basolateral amygdala has robust anxiolytic-like effects in rats. Psychopharmacology (Berl). 2018;235:2947-2955.
19. Richards EM, Mathews DC, Luckenbaugh DA, et al. A randomized, placebo-controlled pilot trial of the delta opioid receptor agonist AZD2327 in anxious depression. Psychopharmacology (Berl). 2016;233:1119-1130.
20. Yang PP, Yeh GC, Yeh TK, et al. Activation of delta-opioid receptor contributes to the antinociceptive effect of oxycodone in mice. Pharmacol Res. 2016;111:867-876.
21. America’s mental health 2018. Stamford, CT: Cohen Veterans Network. October 10, 2018. https://www.cohenveteransnetwork.org/wp-content/uploads/2018/10/Research-Summary-10-10-2018.pdf. Accessed November 25, 2019.
22. Classification of Chronic Pain, Second Edition (Revised). Washington, DC: International Association for the Study of Pain. Updated 2012. www.iasp-pain.org/PublicationsNews/Content.aspx?ItemNumber=1673. Accessed November 25, 2019.
23. Davis B, Vanderah TW. A new paradigm for pain? J Fam Pract. 2016 65:598-605.
24. Defrin R, Ginzburg K, Solomon Z, et al. Quantitative testing of pain perception in subjects with PTSD—implications for the mechanism of the coexistence between PTSD and chronic pain. Pain. 2008;138:450-459.
25. Foa EB, Gillihan SJ, Bryant RA. Challenges and successes in dissemination of evidence-based treatments for posttraumatic stress: lessons learned from prolonged exposure therapy for PTSD. Psychol Science Public Interest. 2013;14:65-111.
26. Miele D, O’Brien EJ. Underdiagnosis of posttraumatic stress disorder in at risk youth. J Trauma Stress. 2010;23:591-598.
27. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, DC: American Psychiatric Publishing; 2013:541.
28. Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372:241-248.
29. Schuchat A, Houry D, Guy GP Jr. New data on opioid use and prescribing in the United States. JAMA. 2017;318:425-426.
30. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. 2001. www.naabt.org/documents/APS_consensus_document.pdf. Accessed November 25, 2019.
31. Fishbain DA, Cole B, Lewis J, et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9:444-459.
32. Volkow ND, McClellan AT. Opioid abuse in chronic pain—misconceptions and mitigation strategies. N Engl J Med. 2016;374:1253-1263.
33. Treede RD, Rief W, Barke A. A classification of chronic pain for ICD-11. Pain. 2015;156:1003-1007.
34. Screening, brief intervention, and referral to treatment (SBIRT). Rockville, MD: Substance Abuse and Mental Health Services Administration. www.samhsa.gov/sbirt. Accessed November 25, 2019.
35. Schneider JP, Davis B. How well do you know your patient? Pract Pain Manag. 2017;17(2). www.practicalpainmanagement.com/resources/practice-management/how-well-do-you-know-your-patient. Accessed November 25, 2019.
36. Schneider JP. A patient-centered approach to the opioid overdose crisis. J Miss State Med Assoc. 2018;59:232-233.
PRACTICE RECOMMENDATIONS
› Screen for developmental and adult trauma, for current trauma symptoms, and for opioid use disorder before tapering an opioid. B
› Refer the patient for in-depth behavioral health evaluation when screening identifies risk of behavioral problems, to identify psychological, behavioral, emotional, cognitive, and social factors pertinent to the prevention, treatment, or management of physical health problems, such as chronic pain. A
› Refer the patient for addiction medicine treatment, either within your practice or to an outside consultant, when screening for opioid use disorder indicates that the patient is at risk. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
