Monday, December 14, 2015
When it comes to pain and opioids, many hospice and palliative care clinicians work to fight against the stigma and fear surrounding these important and powerful medications. We provide education on how how to take opioids safely and how the medications can be most effective to control pain for patients with a serious illness. Despite these efforts to educate, there still may be gaps in knowledge for patients and families and rarely the education can be misperceived as promotion to more hesitant patients, families (and other clinicians).
So how do we balance the stigma-reducing education and appropriate access to opioids, while also respecting the growing public health issues of prescription drug overdose, including suspicion and fears about 'narcotics'?*
Let's review the education about controlled substances in hospice and palliative care organizations. Examine your own practice patterns. What standardized education is provided for patients? Items to cover may include:
- Safe storage and handling
- Symptom and medication tracking
- Drug interactions
- Preventing diversion
- Tolerance vs dependence vs addiction
- Side effects including constipation
- Medication disposal
Your practice, group, or organization may be covering some of these topics but possibly not all of them routinely for every patient. Making this education uniform and standard includes teaching at critical moments such as initiation of opioid therapy, change of opioid medication, and even considering 6- or 12-month intervals to review.
One area many palliative care and hospice programs could be of more assistance is helping patients and families identify safe ways to dispose of opioids (or any medications). In my clinical experience, hospice nurses do a good job of discussing medication disposal with families after the death of a patient. Multiple strong medications may have been prescribed as death neared and the medications clearly do not need to be in the home after the patient has died. But outside of that very unique circumstance, do we talk about medication disposal once patients stop taking certain medications? In my experience, maybe not as often as we should.
I've been familiar with the National Medication Take Back Day for a few years now, but I'm still surprised how many clinicians are not yet aware of it. Supported by the FDA and DEA, this program encourages local pharmacies and law enforcement to work together to securely receive tons (yes, tons!) of medications from shoeboxes and medicine cabinets around the country. Local areas may do this more often than yearly and the FDA also maintains a list of places to dispose of medications all year round. Get familiar with the places near you.
Even simple pamphlets can increase safe disposal rates from 2% to 27%. Still abysmally low, but, hey, we should be starting somewhere. An increasing issue is the response to the important public health concern over opioid deaths. More laws will make it harder to get patients with severe pain access to these important medications. Massachusetts has been seriously flirting with a bill that would limit opioid prescriptions to 7-day fills. The hospice and palliative care community can help preserve this access with visible demonstrations of a responsible approach to these medications.
So what do you do in your own organization? Are there any standard forms or education you would share with the wider community?
Resources for opioid information:
FDA Safe Disposal of Medications
AAHPM Opioid REMS Education (CME Available)
Patient Counseling Document (via CO*RE-REMS)
Pallimed posts about opioids
Christian Sinclair, MD, FAAHPM is a palliative care physician at the University of Kansas and editor of Pallimed. In his spare time he likes to read FDA, DEA and CDC websites.
Image credit: Many Pills via Allen County Wastewater District
Image Credit: Connecticut K-9 Narcotics Unit by fairygift via Amazon