Part II – Risk Defined
BY JIM HUIZENGA, M.D. AND CHIEF CLINICAL OFFICER OF APPRISS HEALTH
Series Introduction – Appriss Health has long held that chronic pain and addiction (substance use disorder) are separate medical conditions and that each deserve a unique clinical approach. We have spent years developing clinical decision support tools and in doing so have obtained the feedback from countless medical professionals, including many pain providers. Through those providers we have also heard (directly and indirectly) from many chronic pain patients as well.
To continue this conversation, over a long series of blog posts, we will explore our approach to benefit/risk assessment, data presentation, and clinical support…and how they relate to our goal of creating a usable and balanced, clinical viewpoint that protects access to care while highlighting areas of risk that clinicians and patients should be aware of.
“Opioids are risky.”
This statement will probably be taken at face value by the vast majority of people in the U.S but it is a complex statement despite the minimal word count. Let’s break it down.
Opioids represent a class of substances that act on the appropriately named “opioid receptor”. These receptors are found in the brain and elsewhere in the body and when activated can decrease the sensation of pain. Activation of these receptors can also cause euphoria (a state of intense excitement or happiness), constipation, nausea and vomiting, itching, and respiratory depression (slowed breathing).
Opioids are historically derived from the opium poppy plant, which was identified thousands of years ago to have medicinal effects. Since then, many more opioids have been engineered and are now readily available, including:
All of the above substances are legitimate medications somewhere in the world and most are widely prescribed within the U.S. (heroin is actually legal in some parts of the world). In fact, according to the CDC, more than 61 million patients had at least one prescription for opioids filled or refilled in 2016. Some of these medications, like carfentanil, are a thousand times stronger than the others and only have legitimate use with large animal veterinarians.
So the term “opioids” encompasses a lot of substances of varying strengths and legality. There are couple of other important ways to break down opioids when discussing risk.
Acute vs. Chronic – Chronic pain is typically defined as pain lasting more than three months and chronic (or long-term) opioid therapy correlates with treatment lasting more than three months when opioids are used on most days. Acute is basically anything less than chronic.
Short acting vs. Long acting – Simply put, some opioids have different durations of effect and therefore can generally fall into short or long acting categories. Confusing as it may be, some drugs can be in both categories. For instance, fentanyl used as an IV medication is short acting with an effect measured in minutes, but when it is used as a transdermal patch is long acting (a single patch lasts three days).
Prescription vs. Illicit – This can be a bit tricky to separate but for our purposes prescription means prescribed for an individual’s use and illicit means not prescribed for someone’s use. All heroin is illicit, and in the last couple of years fentanyl, carfentanil and some other types of opioids have been manufactured illegally and are also considered illicit. Prescription drugs that are diverted from someone with a legitimate prescription to someone else are also illicit.
Now that we’ve outlined the definition of opioids and their various uses, it’s important to understand and better define risk.
For our purposes it’s important to identify, and separate, the types of risk that exist with the use of opioids. Let’s focus on a list that descends in severity:
- Overdose death
- Respiratory depression
- Nausea and Vomiting
- Itching / Rash
The italicized items above are expected risks of using opioids which are typically referred to as side-effects. Dependence is a particularly important risk as it relates (or doesn’t relate) to addiction and that will be the next topic we address in this “Balanced Approach to Opioids and Chronic Pain” blog post series.
The information above can be represented in the following table and then combined into any combination desired to generate a type of opioid risk.
A few example risk statements that can be generated from the above table:
- There is a risk of overdose when using acute, short acting, prescription opioids.
- There is a risk of dependence when using chronic, long acting, prescription opioids.
- There is a risk of overdose death when using chronic, short acting, illicit opioids.
- There is a risk of constipation when using chronic, long acting, prescription opioids.
Each of the above statements represents a type of risk related to opioid use and can lead to 64 possible combinations based on opioid type and risk.
“Opioids are risky” turned out to be a complex three-word sentence, but it’s important to understand the different types of opioids and the risk associated with them if one takes that statement at face value.
In the next blog post, we will discuss Dependence and Addiction.
To read more on this series:
- Part I – Benefit and Risk
- Part II – Risk Defined
- Part III – Dependence and Addiction
- Part IV – PDMPs
- Part V – Multiple Provider Episodes
- Part VI – PDMP Visualization
- Part VII – Interpreting PDMP Visualizations
- Part VIII – Scoring PDMP Data
- Part IX – Understanding How PDMP Data is Scored
- Part X – Machine Learning
- Part XI – Epilogue