Expert Use Best Practices to Protect Patients, Healthcare Workers from Opioid Effects

Nancy Grover

Sarasota, FL ( – Mussels in Puget Sound have tested positive for opioids. That finding last year indicated “a lot of people” are taking oxycodone in the Puget Sound, according to scientists at the Washington State Department of Fish and Wildlife.

That was one of several surprising facts presented to healthcare providers during a webinar on Managing the Consequences of Opioid and Prescription Drug Abuse in Hospitals presented by the Disability Management Employer Coalition. Teresa Bartlett, M.D., SVP Medical Officer at Sedgwick discussed the most recent developments concerning the drugs and how healthcare workers can best deal with affected patients as well as coworkers.

What Opioids Do in the Body
Opioids attach to receptors in the brain that release endorphins, initially increasing pleasure and relieving pain. Repeated stimulation of the receptors causes a tolerance, requiring more of the drug for the same effect. In a fairly short period of time, the receptors become blocked and desensitized to the opioids, causing changes in mood, behavior, breathing, gastrointestinal motion and the person’s perception of pain.

“If you talk to someone on chronic opioid treatment you don’t find them to be particularly happy people because those parts of their brains are literally blocked,” she said.

There are a variety of side effects from the drugs. “Opioids cause the worst constipation of your life,” Bartlett said. “For most people it takes very few doses to get to that level. Now there’s a whole line up of medications [to treat] it.” Other side effects include:

-Limiting the ability to take deep breaths
-Impotence, which can result soon after taking the drugs
-Hyperalgesia, another side effect, causes some people to develop increased sensitivity to pain. “When the brain is barraged with so many opioids and you get somewhere around 80 morphine equivalents or more the drugs themselves start to cause pain. This pain manifests as skin crawling, sweating, maybe muscle aching; often patients feel like they’re in withdrawal or that their pain is increasing,” she said. “Doctors who aren’t aware of this will increase the dose and actually make it worse.”

Older Patients
Medical providers should be especially careful when prescribing opioids to aging workers, Bartlett said. Researchers have found that older people metabolize medications differently.

“There are a lot more drug-to-drug interactions, the medications have a huge impact on the kidney and the liver, they can actually cause dementia and memory loss, and in someone 65 or older, there’s a high likelihood for falls and dizziness,” she said. “We know in hospital systems the risk of falls is huge and the consequences of falls are huge, and if someone is on an opioid then there should be even a higher alert in that setting.”

The Holy Trinity
Some patients will ask for a specific combination of medications by name; including an opioid, benzodiazepine and SOMA — a muscle relaxant that is converted into another benzodiazepine in the body. Called ‘The Holy Trinity’ the combination has a high street value but it is also highly lethal.

Another potentially dangerous combination is tramadol and SSRI medications — antidepressants, such as Lexapro, Zoloft, Paxil or Celexa — which can cause serotonin syndrome.

“Serotonin syndrome will often manifest as sweating, high body temperature muscle rigidity and really high blood pressure,” she said. “It can also cause heart palpitations and irregularities. It is extremely dangerous. So if someone is giving tramadol and not mindful of the other medications that a person might be on, we could be actually causing that iatrogenic or unintended consequence.”

Protecting Workers, Patients
Healthcare workers can be exposed to opioids if, for example, a patient has fentanyl in a powder form. “All you have to do is come in contact with it, and you can also overdose,” Bartlett said. “It can be hands, you can breathe it in, so it’s very important to use the proper precautions.”

Employers in the healthcare industry can protect their workers by adhering to strict employer policies, such as using protective barriers; and by strictly enforcing access points and waste protocols.

Keeping injured workers and others safe is a matter of using best practices when prescribing opioids, such as:

Focus on function. “Pain will seldom kill someone but opioids will,” she said. Also, “look at conducting a risk assessment.”

Random drug screens. The frequency of these should be dependent on the risk level of the patient. Those who are low risk may be tested once a year, while those at high risk should be tested several times a year. The key, she said, is to make sure it is unexpected.

Have an exit strategy by telling the patient the initial prescription is a trial that will be done for a limited, specified period of time to see how the drug works.

Drug holidays. At least once a year, she advises tapering down the opioids to see if the patient is able to function better, or determine if hyperalgesia is present.

PDMPs. She advises physicians to check the prescription drug monitoring program each time they prescribe opioids to see if the patient already has a prescription for the medication and/or to see what other drugs are being prescribed.

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