AOA 2023: Prescribing oral narcotics: Be responsible and use judiciously

Reviewed by Carolyn Majcher, OD, FAAO

Majcher emphasized the importance of health care providers identifying and navigating patient screening by asking about the number of times in the past year they used an illegal drug or used a prescription medication for non-medical reasons. (Adobe Stock / DW labs Incorporated)

Narcotic analgesics have a role in primary eye care and are critical to treating a patient in distress, according to Carolyn Majcher, OD, FAAO, who is in academia in Tahlequah, OK; however, physicians must be aware of the responsibilities associated with narcotic use. She discussed narcotic use in clinical practice at the 2023 American Optometric Association Optometry’s Meeting held in Washington, DC.

In addition to ensuring that opioid therapy is medically indicated and truly needed and considering non-opioid therapies first, clinicians should ensure the prescription is for relief of ocular abnormalities and discuss the risks/benefits of opioid therapy with patients. Clinicians should prescribe the lowest effective dose, ie, one that does not exceed the expected duration of pain (generally 3 days) and advise patients to take the drug only as long as needed.

Clinicians should ensure that no harm is done to the patient and should perform a complete evaluation of their medical status and current medications, and should prescribe immediate-release rather than extended-release and/or long-acting opioids and monitor patients closely.

Majcher also emphasized the clinicians’ responsibility to the public and profession by being involved in screening, recognizing, intervening, and referring patients, as well as serving as a resource for patients living with opioid misuse.

Opioid epidemic

While the opioid epidemic is not a new phenomenon, an acceleration of overdose deaths has occurred since the onset of the COVID-19 pandemic.

Alarming statistics that underscore the need for intervention with these individuals is the 31.96% increase in unadjusted positivity rate for non-prescribed fentanyl, 19.96% increase for methamphetamine, 12.53% for heroin, and 10.06% for cocaine, Majcher noted.

The number of deaths involving prescription opioids in combination with synthetic opioids—largely fentanyl—is rising, in contrast to the number of deaths resulting from prescription opioids alone.

Opioids work on the central nervous system; they bind to various brain, brainstem, and spinal cord receptors.

They work on the reward (mesolimbic) pathway in the ventral tegmental area, which normally is activated by beneficial behavior, causing dopamine release and a pleasurable sensation, which motivates repeating the beneficial behavior.

Normally GABA inhibits dopamine release in the nucleus accumbens, but by binding to receptors on GABA inhibitory neurons, the opioids reduce GABAs activity which ultimately increases dopamine release and induces pleasurable feelings or euphoria.

Stepwise pain management in clinic

In the clinic, optometrists can administer therapies in the following order to manage pain:

• A bandage contact lens with a cycloplegic drug and a topical non-steroidal anti-inflammatory (NSAID) drug
• Oral acetaminophen in a dose of 325 to 650 mg 4 times daily for adults, to a maximum of 3,000-4,000 mg daily
• Oral NSAID such as ibuprofen 400 mg every 4-6 hours for adults
• If an NSAID is ineffective or contraindicated, a codeine plus acetaminophen combination drug or hydrocodone plus acetaminophen combination medication can be considered
• If pain control is inadequate, clinicians can consider the previous step in combination with ibuprofen or may need to consider co-management

Codeine, a schedule III drug, is used to treat moderate pain and relieve cough. It often comes in combination with acetaminophen. The maximal daily dose of codeine is 360mg.

Carolyn Majcher, OD, FAAO

Hydrocodone, a schedule II drug, is a semi-synthetic opioid synthesized from codeine, that is used to treat moderate to severe pain and relieve cough. It also often comes in combination with acetaminophen or ibuprofen.

Majcher advised clinicians to never prescribe extended-release or long-acting opioids and to avoid medications with names followed by ER (which stands for Extended Release) because of the increased risk of addiction, tolerance, and overdose. She also emphasized the importance of educating patients taking combination codeine/hydrocodone plus acetaminophen medications to avoid over-the-counter acetaminophen containing products such as Tylenol to avoid overdose and acute liver failure.

Good practice guidelines

Some of the good practice guidelines for optometrists not mentioned previously include:

• the need for a Drug Enforcement Agency number to prescribe controlled substances
• do not exceed manufacturer’s recommended dosage
• no refills should be included on the initial prescription, and refills should only be given following another an inpatient examination
• document in the patient’s record justification for the prescription
• do not sell controlled substance in the office
• do not prescribe opioids for patients who have received a benzodiazepine within the previous year, to one with a history of substance abuse or drug overdose, or to immediate family members or self
• in most states, controlled substances must be prescribed electronically
• check the appropriate Prescription Drug Monitoring Program before prescribing

Majcher emphasized the importance of health care providers identifying and navigating patient screening by asking about the number of times in the past year they used an illegal drug or used a prescription medication for non-medical reasons. Only 25% of individuals with an opioid disease will receive specialty treatment including a medication-assisted treatment, which is a comprehensive way to address the needs of individuals that combines the use of medication with counseling and behavioral therapies.

Learn more about behavioral health treatment services: https://findtreatment.samhsa.gov/