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As drug misuse and abuse continues to be a significant problem in our
society, more emphasis is being put on health care providers for information
and guidance. When discussing narcotic therapy with your patients, please
consider the following regarding prescribing, safety, and regulations:
Prescribing narcotic therapy
- There is no defined maximum dose for most opioids. The ceiling to analgesic
effectiveness is imposed only by adverse reactions. Adverse effects of opioids
include constipation, nausea and vomiting, dizziness, sedation, and respiratory
depression. Long-term use of high-dose narcotics may also have significant
adverse effects including, but not limited to, endocrinological effects, such
as hypogonadism, impotence in males, menstrual irregularities, and galactorrhea
in women, and opioid-induced hyperanalgesia caused by damage to the nociceptors
thus increasing pain sensitivity.1
- When using combination products, the daily amount of acetaminophen should
not exceed 4 grams, ibuprofen should not exceed 3.2 grams, and aspirin should
not exceed 4 grams (3.9 grams for controlled-, extended-, and delayed-release
products).
- A patient should be referred to a pain specialist when pain is refractory
to increasing doses of opioids prescribed and exceeding 120 mg morphine
equivalent dose, or when treatment is exceeding three months and pain is still
not adequately controlled.2
- Narcotic analgesics are not the only treatment modality for pain.
Conjunctive therapy may include physical therapy; psychotherapy; and adjuvant
medications, such as antidepressants (SNRIs, TCAs), anticonvulsants, muscle
relaxants, and NSAIDs.
Safety precautions
- The combination of a short-acting opioid (i.e., Vicodin®),
muscle relaxant (i.e., Soma®), and benzodiazepine (i.e.,
Xanax®) should be avoided. This is often referred to as the
"Holy Trinity." There is no indication that warrants this combination, and the
effect is a high similar to that of heroin.3
- EvzioTM is a naloxone auto-injector indicated for the emergency
treatment in patients with known or suspected opioid overdose manifested by
respiratory and/or central nervous system depression.4 It is used by
family members, caregivers, and emergency personnel. It is also carried by
first responders in many areas.
- National Prescription Drug Take Back Days is a drug disposal initiative
that occurs every six months and is sponsored by the Drug Enforcement
Administration. If a local Drug Take Back Day is not available, drugs should be
thrown away in the trash after mixing them with an undesirable substance such
as used coffee grounds or kitty litter.5
Legislation/Regulations (PA only)
- SB 1180 is a new bill, signed by Governor Corbett, which will take effect
June 30, 2015, that will create a controlled substance database within the
Pennsylvania Department of Health. This will be an effective tool to help
physicians manage patients who are "doctor shoppers" and not in legitimate
pain.
- Under this new bill, prescribers are not required to submit prescribing
information to the program; however, they are required to query the database
the first time they prescribe each patient a controlled substance and record
the information obtained from the database in the patient's medical record. In
addition, dispensers are required to submit information to the database within
72 hours of dispensing a controlled substance. Note: Please consult with
your own legal counsel regarding your obligations under
SB 1180.
As a reminder, AmeriHealth requires prior authorization on all high-dose and
high-potency narcotics as of January 1, 2015, in an effort to help
facilitate more appropriate usage and prescribing.
When additional help is needed, providers should instruct patients to
contact their mental health/substance abuse services provider. Members with
Magellan Behavioral Health, Inc. coverage can call 1-800-424-4238.
1 Chou R, Franciullo GJ, Fine PG, et al; and the American Pain
Society-American Academy of Pain Medicine Opioids Guidelines Panel. Opioid
treatment guidelines: Clinical Guidelines for the Use of Opioid Therapy in
Chronic Noncancer Pain. J Pain 10:113-130, 2009.
2 Franklin, Gary M. Opioids for chronic noncancer pain: A position
paper of the American Academy of Neurology. Neurology 2014; 83; 1277-1284.
3
http://www.wci360.com/news/article/deadly-drugcombinations-escaping-notice-a-hea
lthesystems-report
4 Facts and Comparisons. Evzio. [Facts and Comparisons web site].
Available at: http://online.factsandcomparisons.com [via subscription
only]. Accessed November 14, 2014.
5 Consumer Health Information. www.fda.gov/consumer. How to Dispose of Unused Medicines.
Accessed November 14, 2014. Magellan Behavioral Health, Inc. manages mental
health and substance abuse benefits for most AmeriHealth members.
Magellan Behavioral Health, Inc. manages mental health
and substance abuse benefits for most AmeriHealth members.
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