Literature Collection

The use of fentanyl and its analogs is the primary driver of deaths related to the opioid overdose crisis. In fall 2021, the U.S. Drug Enforcement Administration issued its first public safety alert in 6 years to raise awareness of the escalating prevalence of fentanyl in counterfeit pills and in other opioids, such as heroin, and nonopioids, such as methamphetamine. In addition to increased public awareness, specific actions are needed to remediate the risk for fentanyl overdose. The authors endorse four principles to address the opioid overdose crisis and provide guidance for remediating its impacts: an incremental approach to behavior change or harm reduction; engagement strategies for individuals with substance use disorder; an integrated care approach to ensure better access to treatment programs and effective interventions; and vigilance among clinicians, program staff, and patients to the threat of fentanyl-adulterated drugs. The authors offer specific recommendations on how to apply these principles effectively within health care systems, communities, and law enforcement agencies across the United States.

BACKGROUND: To provide Centers for Disease Control and Prevention (CDC) guideline-recommended practices for patients on long-term opioid therapy (LTOT) including individualized decisions about opioid dose reduction, we developed the Power Over Pain (POP) Clinic. OBJECTIVE: To describe frequency and reasons for opioid dose reduction and pre-post adherence to CDC guideline-recommended practices. DESIGN: Retrospective chart review with qualitative and pre-post analysis. PATIENTS AND SETTING: Patients at an urban internal medicine teaching practice-prescribed LTOT were seen at POP Clinic at least once. METHODS: Opioid dose reduction was defined by reduction in morphine-equivalent daily dose (MEDD) at 6 and 12 months after the first POP Clinic visit compared to baseline using paired t-tests. Among patients with a dose reduction, reasons documented in POP Clinic notes were qualitatively examined. Dichotomous measures of receiving four CDC guideline-recommended practices (controlled substance agreement [CSA], urine drug testing [UDT], prescription monitoring program review, and naloxone dispensing) at baseline versus 6 and 12 months were compared using McNemar's tests. RESULTS: Of the 70 patients, most were female (66 percent) and Hispanic (54 percent). Forty-three patients (61 percent) had an opioid dose reduction in 12 months after the first POP Clinic visit. The most frequent reason was low or unclear benefit of continuing the current dose (49 percent). Mean MEDD was reduced from 69 mg to 57 mg at 6 months (p < 0.01) and to 56 mg at 12 months (p < 0.01). Completing a CSA, UDT, and naloxone distribution increased at 6 and 12 months (p < 0.01). CONCLUSIONS: Individualized risk assessment in a primary care-based opioid management clinic is feasible and can result in opioid dose reduction and guideline adherence.