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
• Evzio^TM 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

• 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, Independence 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., an independent company, manages mental health and substance abuse benefits for most Independence members.

Magellan Behavioral Health, Inc., an independent company, manages mental health and substance abuse benefits for most Independence Blue Cross members.