News on Opioids

by Karl Steinberg, MD, CMD

CDPH recommends naloxone availability for patients on chronic opioids. This is in response to the quite visible national epidemic of opioid deaths with more intervention recommendations likely to follow.

On August 4, 2014, the CDPH issued an All-Facilities Letter (AFL) in response to the nationwide increase in prescription opioid overdoses.  This letter suggests that prescribers consider “take-home naloxone” for all patients who are on chronic or high-dose opioids, or who use opioids for non-medical reasons, to prevent serious consequences or death from overdoses.  The letter Is online at http://www.cdph.ca.gov/certlic/facilities/Documents/LNC-AFL-14-19.pdf and it refers interested readers to two other documents: 

In our post-acute and long-term care settings, it is commonplace to have a number of residents on high-dose and/or chronic opioids.  Many skilled nursing facilities carry naloxone on their emergency (E-) kits, and this is probably a wise decision.  Keep in mind that naloxone has a very brief duration of action, so if a dose is given and the resident is not sent to the hospital, repeat doses will probably be needed—especially if the resident is on a long-acting opioid where drug levels are expected to take a long time to decline. 

Also keep in mind that naloxone is a very potent opioid antagonist, and it displaces the opioid agonists off their receptors rapidly and completely—this essentially places the patient into sudden opioid withdrawal, which is very unpleasant.  In the case of a heroin overdose who is not breathing, the decision is simple—and many peace officers will probably be carrying the new naloxone auto-injectors routinely in the near future.  But in a patient who is receiving comfort care, naloxone should not be given indiscriminately.

Remember that opioids have fairly low potential to cause serious respiratory depression in general; this tends to happen in cases where a very high dose is given to an opioid-naïve patient, or when opioids are combine with benzodiazepines.

Opioid Medication Update:

On August 18, 2014, tramadol (Ultram, Ultracet) was changed from just a prescription medication to a Schedule IV Controlled Substance.  Tramadol will be subject to all of the usual restrictions of a controlled substance, including limits on refills and the need to count pills each shift in our facilities.  Tramadol had been considered a controlled substance in some states previously, and has been known to have abuse potential since its primary mechanism of action is via opioid mu-1-receptor agonism.

In October, hydrocodone combinations (e.g., Norco, Vicodin, Lortab, Lorcet) will be reclassified from Schedule III to Schedule II.  This will impact our PA/LTC residents by requiring a written prescription, and by not being refillable.  Prescribers should anticipate the same kinds of delays in our residents obtaining these medications as they do with current Schedule II medications like oxycodone, morphine, hydromorphone, etc.  Please keep that in mind so that our patients get the medication they need in a timely fashion.

What do you think about these changes?  Click here to discuss with fellow CALTCM members.