We currently face an unprecedented crisis involving opioids, as anyone paying attention to media reports knows. More people are dying of overdoses than die from vehicular crashes or from gun violence. Many of these overdose deaths, and most of the recently noted increases, involve opioids.
The reasons for the recent increase are multifactorial. One cause is the recent availability of low-cost, high-potency street opioids such as heroin and fentanyl. Another is an attitudinal shift, with many believing that prescription medications are, by their nature, safer than illicitly manufactured drugs.
There has also been a change in many prescribers’ practices in response to education regarding another crisis – the one of under-managed pain. Opioids continue to be the mainstay for the management of many types of pain, including severe acute pain, post-surgical pain, cancer-related pain, and pain associated with terminal conditions. However, as prescribers gain proficiency and become accustomed to utilizing opioids for these problems, many become relatively desensitized to the drawbacks associated with this class of medications.
Opioids are not first-line agents for the management of chronic, non-malignant pain. They have not been proven to be effective for such pain, though admittedly, very little in terms of alternatives has such proof either. Individuals have significant differences in sensitivity to various opioids, based on genomic variances in opioid receptors. Similarly, we have become increasingly aware that some individuals are biologically predisposed to the development of use disorders and addiction, with longer exposure to and higher doses of opioids raising such risk.
Policy-makers, after receiving input from multiple experts, developed a formal multi-pronged plan to address some of these issues presented by the opioid crisis. A balanced approach is the goal, emphasizing both the utility of opioids for severe pain and the risks of opioids when used improperly. One part of this balanced response was the development by the Food and Drug Administration (FDA) of an Opioid Risk Evaluation and Mitigation Strategies (REMS) plan. Originally covering only extended release and long-acting (ER/LA) opioids, it is being expanded to cover all opioid formulations. The REMS made available funds to create education for prescribers and the public, on the safe and balanced role of opioids in modern medical practice.
The American Academy of Hospice & Palliative Medicine (AAHPM) joined with a number of other professional societies to form the Collaborative for REMS Education. CO*RE represents a wide array of professionals, including primary care physicians, nurse practitioners and physician assistants, addiction specialists, oncologists, pain management specialists, as well as hospice & palliative medicine (HPM) physicians. The group has developed education addressing safe and effective opioid prescribing, appropriate use of opioid antagonists, opioid safe storage and disposal, abuse-deterrent formulations, addiction and use disorder screening, and prescribing in special populations. To date, CO*RE has provided more Opioids REMS education across the nation than any other group.
Now in its sixth edition, the CO*RE curriculum is called Opioid Prescribing: Safe Practice, and reinforces what all prescribers should understand about opioids in today’s regulatory and political climate. In September 2017, Dr. Ronald Crossno and Dr. Daniel Fischberg presented this information in a 2-hour webinar, providing an HPM slant to the material. This webinar was recorded and is now offered as a CME-accredited, REMS-compliant training on the AAHPM online store. This is provided free of charge, as required by the Opioid REMS blueprint. Participating in the webinar and finishing the associated post-test results in the clinician being designated a “Completer”, meaning the Completer can show proof of having taken the course, if such education is ever mandated.
Whether you are new to the field or an old pro at opioid prescribing, we encourage you to take the Opioids Prescribing: Safe Practice course and to complete the associated post-test. Virtually everyone who has taken it has admitted to learning something new, which they can incorporate into practice.
Submitted and written by Ronald J. Crossno, MD HMDC FAAHPM and Daniel Fischberg, MD PhD FAAHPM
Opioid therapy has the unwanted consequence of fecal impaction. There is a new product for fecal disimpaction in the market called FI-IT which is available on amazon. Please let me know what is the experience palliative care organizations/ nurses have for disimpacting stool with this product as opposed to digital evacuation of fecal impaction. I would like to implement this in our practice if it is a good tool. Now a days most of the time we have to send patients to the hospital for fecal disimpaction ( which is a billable proceedure).