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Keywords:

  • Chronic pain;
  • evidence-based practice;
  • health care policy issues

Case study

  1. Top of page
  2. Case study
  3. Introduction
  4. Heroin
  5. Implications for practice
  6. Conclusion
  7. References

Justin Smith, a 26-year-old Caucasian male, presents to the clinic for a follow-up visit related to medical management of his chronic low back pain. For the past 4 months, he has been receiving biweekly physiotherapy including stretching and back strengthening exercises, low-impact aerobic conditioning, and spinal manipulation. Along with these treatment methods, he has been receiving Oxycodone for pain relief. The physical rehabilitation team is in the process of weaning the patient off this medication since he has been progressing as expected.

The patient's Kentucky All Schedule Prescription Electronic Reporting (KASPER) report (Kentucky Cabinet for Health & Family Services, 2013) demonstrates he has only received scheduled prescriptions including Oxycodone from this office. At today's visit, his wife expresses concern that Justin has recently begun exhibiting impulsivity in his decision-making.

Introduction

  1. Top of page
  2. Case study
  3. Introduction
  4. Heroin
  5. Implications for practice
  6. Conclusion
  7. References

Over the last 100 years, drug control policy has centered on one of two aspects: supply and demand reduction. Although research has demonstrated it to be much more cost-effective to focus efforts on demand reduction through education, prevention, and treatment, most policies over time have centered on supply reduction through legislation and enforcement of law (Catalano, 2009). The Harrison Act of 1914 was the first piece of legislation that criminalized the prescription of narcotics to known addicts. Sixty years later, the Drug Enforcement Agency (DEA) was provided the ability to prosecute medical providers through the Drug Abuse and Prevention Control Act of 1975 for inappropriate prescribing of scheduled drugs (Catalano, 2009). Today, this has led to the development of state-run prescription monitoring programs (PMP) such as KASPER (Kentucky Cabinet for Health & Family Services, 2013). Currently, 37 states have fully operational PMPs with another 11 states having passed legislation to develop them. It is common for both prescribers and designated medical surrogates (i.e., Registered Nurse) to have access to PMP information databases, and they must evaluate patient reports periodically as determined by state laws (U.S. Department of Justice, Drug Enforcement Agency, Office of Diversion Control, 2011).

Prescription monitoring programs primarily serve the purpose of alerting governmental agencies such as the DEA along with law enforcement on inappropriate prescribing of controlled medications by medical providers along with seeking of such prescriptions by patients (Catalano, 2009). Thus, more responsibility and attention has shifted to medical providers resulting in increased DEA prosecution of prescribers (Catalano, 2009; McMullen & Howie, 2011). Adding to this dilemma is the knowledge that many nurse practitioners have had limited clinical experience in chronic pain management and often do not follow evidence-based practice guidelines in its treatment (McMullen & Howie, 2011). Compounding the aforementioned issue is the unintended consequence of patients seeking heroin as a substitute since more oversight has occurred with prescription opioids (Peavy et al., 2012; Yee, Hughes, Atayee, Best, & Pesce, 2011).

Heroin

  1. Top of page
  2. Case study
  3. Introduction
  4. Heroin
  5. Implications for practice
  6. Conclusion
  7. References

Heroin is a morphine derivative with greater potency and addiction risk due to its highly euphoric properties. Based on the Controlled Substances Act of 1970, heroin is considered to have no acceptable medical use. Heroin can be injected, smoked, snorted, used as a suppository, or orally ingested; however, it is most commonly used by snorting or injection due to these routes being able to produce a greater amount of euphoria (Drug Information Online, 2013). Although the estimated prevalence of heroin use in the general population is approximately 0.1%, prevalence rates in the chronic pain population treated with opiates is three times higher (Yee et al., 2011). Risk factors for heroin use include: male gender; younger age; Caucasian race; prior usage of opiates for at least 4 months duration (Peavy et al., 2012); concomitant use of methadone or Oxycodone (Yee et al., 2011); and impulsivity (Marino et al., 2013). Due to the short half-life of heroin, gas chromatography followed by mass spectroscopy to detect the heroin metabolite and 6-acetylmorphine (6-AM) is the recommended laboratory test with a high level of morphine and 6-AM in the urine being a positive result (Tenore, 2010; Yee et al., 2011).

Implications for practice

  1. Top of page
  2. Case study
  3. Introduction
  4. Heroin
  5. Implications for practice
  6. Conclusion
  7. References

Heroin abuse increases the risk of infectious diseases (Peavy et al., 2012) including Hepatitis B and C along with Human Immunodeficiency Virus resulting in adverse outcomes for not only individuals but also public health. This coupled with increased legal responsibility of prescribers in management of pain in patient populations should direct practitioners to be more diligent in addressing the issues surrounding aberrant drug-taking behaviors. Efforts to positively affect drug control policy (Catalano, 2009) through both supply reduction (i.e., appropriate prescribing) and demand reduction (i.e., prevention education, treatment) is best accomplished through the use of evidence-based practice guidelines.

While guidelines for prescribing chronic pain medication therapies have been developed by reputable organizations such as the World Health Organization and American College of Physicians, the American Pain Society (APS) and American Academy of Pain Medicine (AAPM) have developed a multidisciplinary, evidence-based best practice guideline for prescribing scheduled medications in chronic pain populations (McMullen & Howie, 2011). This clinical guideline addresses 14 recommendations (Chou et al., 2009) for chronic opioid therapy (COT):

  1. Patient Selection and Risk Stratification: proper evaluation of pain benefit versus substance abuse risk through a complete history and physical examination focused on risk for substance abuse through appropriate assessment and diagnostic testing.
  2. Informed Consent and Opioid Management Plans: counsel patients fully on the benefits and risks associated with COT along with delineation of responsibilities and expectations for both the prescriber and patient.
  3. Initiation and titration of COT: initial treatment should be a therapeutic trial individualized to patient characteristics and responses lasting several weeks to months.
  4. Methadone: should only be used with great caution due to its lack of research documented benefit and increased risk of death.
  5. Monitoring: patients should be reassessed periodically (or more often if aberrant drug-taking behaviors are suspected) through urine drug screens and other information abilities such as PMPs with frequency based on risk stratification.
  6. High-Risk Patients: only consider COT if more stringent monitoring parameters can be agreed upon. Consider referral for assistance in management of COT in these cases.
  7. Dose Escalations, High-Dose Opioid Therapy, Opioid Rotation, and Indications for Discontinuation of Therapy: evaluate risk versus benefit along with adverse effects in relation to both titrating and tapering of doses, medication rotation, and discontinuation.
  8. Opioid-Related Adverse Effects: be prepared to manage associated adverse effects including constipation, nausea, vomiting, sedation, hormonal deficiencies, pruritus, and myoclonus.
  9. Use of Psychotherapeutic Co-interventions: use adjunct therapies including nonopioid medications along with nonpharmacological interventions.
  10. Driving and Work Safety: counsel patients about cognitive impairments affecting activities and to avoid such activities when there are signs and symptoms of impairment.
  11. Identifying a Medical Home and When to Obtain Consultation: there should be one primary responsible clinician who oversees multidisciplinary pain management.
  12. Breakthrough Pain: consider as needed opioids based on risk versus benefit.
  13. Opioids in Pregnancy: encourage minimal to no use based on individualized benefit versus risk assessment findings.
  14. Opioid Policies: be aware of current laws and regulations dictating the use of COT.

Conclusion

  1. Top of page
  2. Case study
  3. Introduction
  4. Heroin
  5. Implications for practice
  6. Conclusion
  7. References

Drug control policies continue to place more legal responsibility on the medical practitioner for reducing aberrant drug-taking behaviors through appropriate prescribing practices (Catalano, 2009); however, it has resulted in an unintended consequence of patients seeking heroin as an alternative to opioid prescriptions due to its relative accessibility, cheaper cost, ability to produce similar effects to prescription opioids, and less regulatory oversight (Peavy et al., 2012). As a result, it is imperative healthcare providers including nurse practitioners utilize evidence-based best practice strategies for pain management with COT.

Based on clinical practice guidelines developed by the APS and AAPM for COT pain management (Chou et al., 2009), it's important that prescribers: continuously assess benefit versus risk; monitor for aberrant drug-taking behaviors; utilize nonopioid pain management therapies; have one clinician who assumes primary responsibility for care; have knowledge of opioid prescribing policies; and refer to an addiction specialist when appropriate. Mr. Smith possesses several risk factors for heroin abuse: male gender; younger age; Caucasian race; impulsivity; and having been on an opiate prescription for at least 4 months duration. In addition, the specific use of Oxycodone in his treatment places him at a significantly higher risk of heroin abuse when compared to other opioid prescription alternatives (Yee et al., 2011). Although Mr. Smith's KASPER report demonstrated no doctor shopping activities, urine gas chromatography with mass spectroscopy detected a high level of morphine and 6-AM indicating positive use of heroin. The urine drug screen was ordered due to a positive assessment by the rehabilitation nurse in the use of the clinical opiate withdrawal scale (COWS), an 11-item tool designed to identify opiate withdrawal and physical dependence (Wesson & Ling, 2003).

When confronted, Mr. Smith admitted to snorting heroin over the past 6 weeks. He indicated awareness of the KASPER reporting system through mandatory disclosure in the medical office (KASPER, 2013) which partially led to his decision in seeking heroin as an alternative since it was cheap and readily accessible through acquaintances. As a result of this revelation, Mr. Smith's nonopioid therapies including stretching and back strengthening exercises, low-impact aerobic conditioning, and spinal manipulation were increased to four times per week, and ultrasound heat therapy was added to the regimen. His opioid prescription was changed from Oxycodone to Percocet at a comparable dosage. He was also referred to an addiction specialist who will assume responsibility for weaning him off the opiate prescriptions while addressing the heroin abuse. This referral included encouragement of family attendance to self-help groups such as Al-Anon or Narcotics Anonymous.

Since heroin abuse is often the result of unintended consequences from balancing patient medical management with drug control policy requirements, research in the prevention and identification of heroin abuse in patients on COT is lacking. More evidence is needed in identifying risk screening tools specific to heroin abuse along with prevention education components for best practice. In addition, guidelines tailored to monitoring strategies including recommendations for frequency need to be evaluated for best practice.

Key Practice Points
  • Drug control policy through supply reduction has placed more legal responsibility on medical prescribers including the required monitoring of scheduled prescriptions with patients though state-run prescription monitoring programs (PMP).
  • An unintended consequence of these state PMPs includes the abuse of heroin due to the increased regulatory oversight of prescription opioids.
  • Proper monitoring practices include the periodic evaluation of state PMP reports; assessment of patients using the clinical opiate withdrawal scale (COWS) tool; and gas chromatography followed by mass spectroscopy to detect the heroin metabolite, 6-acetylmorphine.
  • If heroin abuse is suspected in patients on chronic opioid therapy, referral to an addiction specialist and self-help groups such as Al-Anon and Narcotics Anonymous is recommended.
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References

  1. Top of page
  2. Case study
  3. Introduction
  4. Heroin
  5. Implications for practice
  6. Conclusion
  7. References
  • Catalano, J. (2009). Pain management and substance abuse: a national dilemma. Social Work in Public Health, 24, 477490.
  • Chou, R., Fanciullo, G.J., Fine, P.G., Adler, J.A., Ballantyne, J.C., Davies, P. et al. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, 10(2), 113130.
  • Drug Information Online. (2013). Heroin. Retrieved October 25, 2013, from http://www.drugs.com/heroin.html
  • Kentucky Cabinet for Health and Family Services (2013). KASPER (Kentucky All Schedule Prescription Electronic Reporting). Office of Inspector General. Retrieved October 25, 2013, from http://chfs.ky.gov/os/oig/KASPER.htm
  • Marino, E.N., Rosen, K.D., Gutierrez, A., Eckmann, M., Ramamurthy, S., & Potter, J.S. (2013). Impulsivity but not sensation seeking is associated with opioid analgesic misuse risk in patients with chronic pain. Addictive Behaviors, 38(2013), 21542157.
  • McMullen, P., & Howie, W. (2011). Prescribing chronic opioid therapy in noncancer patients experiencing chronic pain: legal and practice considerations. The Journal for Nurse Practitioners, 7(9), 733739.
  • Peavy, K.M., Banta-Green, C.J., Kingston, S., Hanrahan, M., Merrill, J.O., & Coffin, P.O. (2012). “Hooked on” prescription-type opiates prior to using heroin: results from a survey of syringe exchange clients. Journal of Psychoactive Drugs, 44(3), 259265.
  • Tenore, P.L. (2010). Advanced urine toxicology testing. Journal of Addiction Diseases, 29, 436448.
  • U.S. Department of Justice- Drug Enforcement Agency: Office of Diversion Control. (2011). State Prescription Drug Monitoring Programs. Retrieved October 31, 2013, from http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm
  • Wesson, D.R., & Ling, W. (2003). The clinical opiate withdrawal scale (COWS). Journal of Psychoactive Drugs, 35(2), 253259.
  • Yee, D.A., Hughes, M.M., Atayee, R.S., Best, B.M.D., & Pesce, A.J. (2011). Observations on the relationship between opioid medications, illicit drugs, and heroin use in pain patients. American Journal of Pharmacology and Toxicology, 6(1), 510.