The role of healthcare professionals in opioid addiction prevention

Jan. 17, 2024

Opioid addiction, also called opioid use disorder (OUD), has become a top national public health concern. According to the American Medical Association (AMA), 3% to 19% of individuals exposed to opioids develop chronic dependency. Certain risk factors can increase these odds. The most severe OUD complication is fatal overdose, which occurs every six minutes in the U.S. Opioid-related overdoses are now the driving cause of accidental death in adults under age 45 and have lowered average American life expectancy, according to the Centers for Disease Control and Prevention (CDC). Approximately 1 in 5 Americans knows someone who has died due to the effects of this drug class, according to the Report on the Economic Well-Being of U.S. Households in 2017.

It is imperative that the medical community identifies mechanisms to balance these drugs' medicinal powers with their toxicity, says Holly L. Geyer, M.D., a hospitalist and addiction medicine specialist at Mayo Clinic in Arizona. Dr. Geyer chairs the Mayo Clinic Arizona Opioid Stewardship Program, is the editor of the patient education book Ending the Crisis: Mayo Clinic's Guide to Opioid Addiction and Safe Opioid Use, and is a contributor to the Mayo Clinic Opioid Resource Center.

Over-prescribing remains an opioid epidemic contributor

Opioid prescribing soared from the 1990s to early 2000s. By 2015, more than 1 in 3 U.S. adults received an opioid prescription. But national prescribing trends stabilized as prescribers acclimated to prescribed opioids' addictive potential, according to a 2017 publication in Annals of Internal Medicine. However, a parabolic rise in opioid-related overdoses continues trending upward today as patients dependent on opioids who became unable to access opioids from their prescribers turned to the illicit drug market.

"Multiple early studies have shown more than 80% of individuals who move to illicit opioids — particularly heroin — started on prescription opioids, according to the National Institute on Drug Abuse," Dr. Geyer explains. "Roughly half of them obtain these from friends or family through diversion."

A Mayo Clinic quality improvement project identified that patients who had surgery consumed an average of one-third of opioids provided; 70% of patients with leftovers stored them for future use.

"Studies have shown that patients experiencing euphoria after opioid use are more likely to develop addiction."

— Holly L. Geyer, M.D.

"Leftover opioids cause problems, especially when used for indications other than prescribed," says Dr. Geyer. "They are particularly dangerous when they get into the hands of kids who can't handle the dose or potency."

Patient, indication, dose, route and length of treatment matter

Dr. Geyer views opioid stewardship as a central tool to prevent opioid addiction.

"Opioid stewardship requires healthcare professionals' understanding of the critical role they play as opioid gatekeepers," says Dr. Geyer.

Preventing OUD requires that healthcare professionals pay attention to details. Patients also need OUD screening to ensure appropriate treatment and to prevent opioids from entering the illicit market.

Factors that significantly increase addiction risk include:

Younger age, or patients ages 18 to 45.
Chronic pain.
Personal or family substance misuse history, including tobacco.
Mental health disorders.
Life stressors.
Prolonged opioid use for more than 7 days.

Dr. Geyer explains that it is an opioid prescriber's responsibility to ensure administration of this medication to the right patient. Additionally, the prescriber must make certain the prescription is for the right indication and prescribed at the right dose, route and treatment length, as follows:

The right indication

Ensuring an opioid prescription for the right indication is critical. Multiple studies have concluded that opioids offer little value for chronic pain, often defined as pain present more than 45 days. Further, these studies often found that opioids worsen symptoms through opioid-induced hyperalgesia.

"We've learned a lot in the past two decades about which conditions respond to which pain regimens," says Dr. Geyer. "Many studies have found nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen to be as effective as opioids for acutely painful condition management and some post-surgical states. Disease indication-based practice protocols limit unnecessary opioid exposure."

The right dose, route and treatment length

Tailoring prescription length is key for OUD prevention. A CDC study showed a one-day opioid prescription carries a 6% chance the person will still use the opioid at one year, according to a Morbidity and Mortality Weekly Report in 2017. If the healthcare professional increases to an eight-day prescription, the risk goes up to 13.5%. A monthlong prescription drives the risk to 30%. For every opioid prescription refill, risk of ongoing use at one-year doubles.

Opioid administration route is also impactful. For inpatients, an oral route rather than intravenous limits the euphoric surge patients may experience when first-pass metabolism is bypassed.

"Studies have shown that patients experiencing euphoria after opioid use are more likely to develop addiction," Dr. Geyer adds.

Remaining mindful of these opioid prescription factors in medical practice is complex; it is important to approach each case individually, says Dr. Geyer.

6 key actions in opioid stewardship

After screening patients to ensure opioid appropriateness, Dr. Geyer recommends the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain and its suggestions for good opioid stewardship:

Check the prescription drug monitoring program. Look for multiple prescriber history, which may suggest doctor shopping. Watch for history of other controlled substances such as benzodiazepines or muscle relaxants, which could increase opioid overdose risk.
Educate through risk-benefit discussions, ensuring that patients understand opioid use guidelines. Patients prescribed opioids must know when to take them; what to avoid, such as sedatives and alcohol; and what to monitor for, such as constipation, addiction and overdose. Patients also must be informed about the importance of locking up opioids to make them inaccessible to others and how to immediately dispose of unused pills.
Always pair an opioid with a nonopioid alternative. Consider scheduling acetaminophen or NSAIDs round-the-clock to reduce opioid need. Nonpharmacologic therapies such as physical therapy, daily exercise, heat therapy and massage therapy can be used as adjuncts.
Avoid opioid use for chronic or undifferentiated pain. If patients require opioid therapy beyond 45 days or have no obvious symptom driver, consider referring to a pain management specialist for unexplored alternatives and adjunctives.
Offer naloxone. Offer this medication to all patients receiving opioid prescriptions, especially if they have a history of breathing problems, kidney or liver dysfunction, or substance use disorder.
Develop rapport with the patient. Dr. Geyer says she feels the best opioid addiction prevention strategy is an open and honest relationship with the patient.