This transcript is automatically generated.
00:00:05 Narrator
Welcome to Rumor vs Truth, your trusted source for facts, where we dissect the evidence behind risky rumors and reveal clinical truths. Today, we'll discuss the pain points around opioids.
00:00:21 Steve Small
Now, before we start talking about claims today, Don, I've got a fun fact that will make your day. Rumor vs Truth has now reached over 50,000 downloads.
00:00:31 Don Weinberger
I'm giving that claim a verdict of true, no conditions. And thank you to our listeners for being our dedicated audience, tuning in to learn more as we untangle risky rumors from clinical truths.
00:00:43 Steve Small
And I'm just glad folks don't think our puns are as painful as we thought. And with that, I'm Steve the pharmacist.
00:00:50 Don Weinberger
And I'm Don the pharmacist. And speaking of painful puns, we're going to talk about opioid claims in this episode to see which ones are true versus which ones need a rescue dose of evidence.
00:01:02 Steve Small
Right, and these rumors don't just cause confusion, right? They can affect pain care, overdose response, and how we treat patients with opioid use disorder.
00:01:12 Don Weinberger
And this feels especially important right now. The opioid conversation has changed a lot for the past few years. Clinicians are trying to balance appropriate pain treatment with safety concerns, new non-opioid options, are entering the market and old assumptions about mild opioids are being challenged by newer evidence.
00:01:30 Steve Small
So if you learned your opioid pearls years ago and haven't revisited them recently, this episode might surprise you.
00:01:38 Don Weinberger
And should we give the audience our lineup, Steve?
00:01:41 Steve Small
Well, hold on to your white coat Don. We're going to talk about why dependence risk may start earlier than many clinicians assume, whether the new drug suzetrigine is actually the opioid alternative it's marketed as, why antihistamines frequently disappoint for opioid-induced itching, and why opioid use disorder does not automatically rule out opioid treatment for pain.
00:02:03 Don Weinberger
That's a lot of clinical territory to cover, Steve. We need to titrate the puns, monitor for evidence gaps, and avoid breakthrough nonsense.
00:02:12 Steve Small
And let's keep the nonsense to a minimum by taking a moment to remind our listeners that this podcast offers continuing education credit for pharmacists, pharmacy technicians, prescribers, and nurses.
00:02:24 Don Weinberger
Just log into your pharmacist letter, pharmacy technician's letter, or prescriber insights account and look for the title of this podcast in the list of available CE courses.
00:02:33 Steve Small
And for the purposes of disclosures, none of the speakers today have anything to disclose.
00:02:39 Don Weinberger
Steve, opioids are one of the topics where two things can be true at once. they could be essential for managing pain, but they can carry serious risks if we get casual with the details.
00:02:51 Steve Small
Right. The problem is that the casual details become clinic hallway wisdom. Like short courses are always safe, higher naloxone is automatically better, and even conversion tables are exact. Codeine works for cough, like the list goes on. And it sounds tidy, but the evidence is messier.
00:03:09 Don Weinberger
And today's claims cover both sides, avoiding unnecessary opioid harm, but also making sure patients who need pain treatment, especially patients with opioid use disorder, aren't dismissed or undertreated.
00:03:22 Steve Small
Yeah, so the theme today is not opioids bad or opioids good. It's opioids require nuance, which is the least catchy slogan ever, but clinically very useful.
00:03:36 Don Weinberger
Let's get into the evidence carefully, because this is 1 place where shortcuts can cause real problems.
00:03:42 Steve Small
Right. Let's start with a claim that challenges something a lot of clinicians have probably thought at some point. It's only a few days of opioids. What harm can that do? So the claim is that dependence risk can increase soon after initiating opioids.
00:03:56 Don Weinberger
I'm glad we're looking at this first. Before we go any further, we should clarify something. So physical dependence occurs with repeated use, causing the neurons in the brain to adapt so they can only function normally when a patient is taking the drug. So taking away the drug can cause several reactions or withdrawal symptoms.
00:04:18 Steve Small
And let's not confuse that with addiction or opioid use disorder, which is a chronic disease where patients develop uncontrollable drug-seeking behavior despite negative consequences, and it involves long-lasting changes in the brain.
00:04:33 Don Weinberger
So with dependence, what's the time frame? And do we have studies on this?
00:04:39 Steve Small
We have some evidence. An important observational study back from 2017 looked at opioid naive adults, so folks that had not taken opioids yet, and found that the probability of long-term opioid use increased with each additional day of meds supplied. And the curve started changing early with notable increases after about day five and again after longer initial supplies.
00:05:05 Don Weinberger
Okay, so this makes sense. the longer you're on it, the more the brain will be adapted to it and increasing the risk of dependence. But that five days actually might surprise some though.
00:05:16 Steve Small
Yeah, and now a more recent 2023 study looked at more outcomes, things like risk of opioid misuse, poisoning, or dependence.
00:05:25 Steve Small
And this study was big, looking at almost 1,000,000 patients who received opioids in Spain between 2012 and 2018. And they found the risk increase for opioid prescriptions written for a four day supply or longer.
00:05:39 Don Weinberger
So clinically, this supports thoughtful initial prescribing. Use opioids when appropriate, but don't treat the first prescription as harmless just because it is short. Time isn't exactly on our side.
00:05:53 Steve Small
Exactly. And risk still appears to exist with short courses. So when it comes to this claim that dependence risk can increase soon after initiating opioids, the verdict is true.
00:06:08 Don Weinberger
So the practical takeaway here is, you know, don't assume a short course is automatically a low risk course. Dependent risk can begin increasing sooner than many clinicians realize. Ensure opioids are prescribed for the lowest effective dose of opioids for the shortest duration needed.
00:06:25 Steve Small
And that's why opioid stewardship isn't just about avoiding long-term use. It's about making thoughtful decisions from the very first prescription. An important initial strategy to limit opioid needs is to optimize non-opioid meds like acetaminophen or ibuprofen first, while also using non-drug strategies, things like physical therapy.
00:06:45 Don Weinberger
Right. And don't walk away thinking that four to five days is a hard and fast rule. We know risks can vary case by case, and be weighed against benefits.
00:06:56 Steve Small
Right. As an example, while three to five days of opioids may be appropriate for most cases of postoperative pain, some patients may need more than seven days if they've had severe trauma or multiple injuries, things like that.
00:07:08 Don Weinberger
So see our opioid stewardship checklist to help you limit risks when you write, verify, or dispense prescriptions. Okay, so next up is a newer drug that has gotten a lot of attention because everyone wants better pain relief, without that opioid baggage. My claim is Suzetrigine is safer than opioids.
00:07:27 Steve Small
Suzetrigine brand name Journavx. I hope I'm saying that right Don.
00:07:32 Don Weinberger
Good Job! I think you are.
00:07:34 Steve Small
And that's definitely made a splash recently. There's been plenty of interest in it since we've seen, or rather we haven't seen, a new pain med class like this approved for really over 2 decades.
00:07:46 Don Weinberger
All right. And before we start, let's be clear about something, safer depends on what risk you're talking about. Regarding addiction potential, it's not an opioid or controlled substance. Instead, suzetrigine is a sodium channel blocker that targets pain signals in the peripheral nervous system.
00:08:05 Steve Small
Essentially meaning it doesn't do much in the brain itself, which is good because that's part of the issue with how opioids cause dependence and addiction by affecting the brain's reward centers.
00:08:16 Don Weinberger
plus it avoids other opioid side effects such as respiratory depression.
00:08:22 Steve Small
So I could see it being safer in that respect, right? But safety is only part of the equation. How well does it actually treat pain, Don?
00:08:29 Don Weinberger
Right. So we have randomized controlled trials in adults that showed its use for moderate to severe acute pain after certain surgeries, mostly abdominoplasties or, you know, tummy tucks or bunionectomies, and they found that suzetrigine reduced pain more than placebo. And pain reduction was similar when compared to patients taking hydrocodone and acetaminophen, 5, 325 milligram strength.
00:08:55 Steve Small
So it's better than placebo, but hydrocodone and acetaminophen, it seems like a weak opioid choice for most cases involving post-op pain, at least that I've seen, even if the study's looking at bunionectomies, right?
00:09:10 Don Weinberger
And this is where the condition part walks in, wearing sensible shoes.
00:09:15 Steve Small
Always with sensible shoes.
00:09:18 Don Weinberger
Typically see that low hydrocodone acetaminophen dosage used in other surgeries, especially not for major and intensive surgeries. And these studies only looked at using it up to two weeks, which is a reasonably short duration. So this is hard to apply to a lot of cases. And we don't have a lot of data commonly to say Suzetrigine will really step up to the plate there.
00:09:42 Steve Small
Yeah, time will tell with more evidence. And Suzetrigine has drug interaction issues, specifically CYP3A pathways, right? So it may not be the safest option depending on patients' other meds.
00:09:54 Don Weinberger
Plus, it's costly. It's about $15 a pill, which can represent insurance barriers. Even a medication with advantages on paper isn't particularly helpful. Insurance barriers or waiting for authorizations prevents patients from actually receiving it. So going back to that claim, Suzetrigine is safer than opioids and the verdict is true with conditions.
00:10:21 Steve Small
So it's safer than opioids in important ways? Yes, especially regarding addictive potential and some opioid type adverse effects.
00:10:30 Steve Small
But don't turn non-opioid here into a synonym for risk-free, right? Suzetrigine comes with a different set of trade-offs than opioids, like questions around pain control, duration, interactions, and obviously cost.
00:10:43 Don Weinberger
Yeah, so I like to think of Suzetrigine as a promising non-opioid option for short-term acute pain, not a universal replacement for every opioid in every pain scenario.
00:10:56 Steve Small
Yeah, and don't compare it to opioids only by asking, does it work? Also ask for whom, for how long, with what interactions, and compared with what alternatives. I'm sure some clinicians listening are asking, well, should then we be excited about this new med?
00:11:14 Don Weinberger
Oh, we can celebrate all we want. Just don't let excitement replace critical thinking.
00:11:19 Steve Small
Which might be the unofficial theme of this entire podcast, to be honest.
00:11:25 Don Weinberger
You know what else is exciting?
00:11:26 Don Weinberger
We also have a list of other non-opioid meds that might help your patients in our analgesics for acute pain in adults resource. It can help you compare options, including suzetrigine. And speaking of resources.
00:11:41 Steve Small
Yeah, we've linked directly to several related TRC resources in the show notes, including tools on opioid prescribing, opioid safety, and pain management.
00:11:51 Don Weinberger
If you aren't already a subscriber, don't miss out on these resources.
00:11:55 Don Weinberger
Sign up today with listener code RVT1026 at checkout to get 10% off to help you stay ahead with trusted insights and tools.
00:12:04 Steve Small
And with that, now we're going to do more than just scratch the surface with this next claim. It's that antihistamines are very effective for opioid induced pruritus or itching.
00:12:16 Don Weinberger
So I feel like I commonly see antihistamines like diphenhydramine and hydroxyzine used for opioid induced itching or pruritus. But now I'm second guessing the evidence.
00:12:29 Steve Small
And perhaps you should, Don. Itching can occur with certain opioids, commonly codeine and morphine is the most common. But since these meds increase histamine release, right? But this is generally not considered an allergic reaction. Think of it more of as a side effect.
00:12:45 Don Weinberger
But, you know, I could see folks might think histamine equals itching and histamine equals fixed.
00:12:52 Steve Small
And histamine may play a role, but it isn't the whole story here. Opioid receptors themselves appear to contribute a little bit to the itching response, which helps explain why antihistamines often underperform.
00:13:04 Steve Small
Most evidence we have for antihistamines are actually from studies involving pregnant women receiving diphenhydramine for itching from opioid epidurals, you know, during labor and delivery. And diphenhydramine studies wasn't much better than placebo for preventing itching.
00:13:19 Don Weinberger
And it's hard to extrapolate that trial data to other scenarios and populations.
00:13:25 Don Weinberger
That situation would never apply to you and me, Steve.
00:13:29 Steve Small
Very true, Don. Plus, there might be more effective options. A handful of studies looking at IV opioid antagonists like nalbuphine and low-dose naloxone infusions for treatment of morphine epidural pruritus show that they perform better than placebo and sometimes antihistamines.
00:13:48 Don Weinberger
So then why do you think antihistamines stick around for this?
00:13:53 Steve Small
Don, I'm wondering if it's probably the sedation. Maybe they don't directly treat the itching. Maybe some patients perceive relief because they're less aware of the itch or scratch less. It literally just makes you forget your itching.
00:14:06 Don Weinberger
Right. So yeah, if you're asleep, you're not really itching, right? So it's more like it makes you forget you're itchy rather than targeting the problem. Plus, you know, I worry that combining antihistamines can worsen opioid side effects like drowsiness or slowed breathing, even worsen things like constipation and urinary retention.
00:14:26 Steve Small
and that's where I worry too. If we're adding a sedating antihistamine to a sedating opioid, we may be ending up increasing drowsiness and other unwanted effects without really solving the itch problem. So when it comes to this claim that antihistamines are very effective for opioid induced pruritus, the verdict is rumor with conditions.
00:14:50 Don Weinberger
Antihistamines aren't necessarily a reliable way to manage itching from opioids based on limited evidence that we have.
00:14:58 Steve Small
Right, first, avoid opioids that are prone to itching in the 1st place, like codeine or morphine, when possible. And use options up front or switch to ones with lower risk, such as oxycodone.
00:15:09 Don Weinberger
If the patient has itching in the hospital, consider IV nalbuphine or low dose naloxone infusion.
00:15:15 Steve Small
You see those all the time. And if the medical team or patient still wants to try an antihistamine, lean towards a less sedating option. I'm thinking options like cetirizine or loratadine to limit those sedating side effects.
00:15:27 Don Weinberger
So the bottom line isn't that antihistamines never work, it's that data show we can't say they're very effective.
00:15:37 Steve Small
And before labeling a patient as having an opioid allergy because of this itching, make sure you're distinguishing A predictable side effect from a true allergic reaction here.
00:15:48 Don Weinberger
And that's where our investigating possible drug allergy or sensitivity resource can help.
00:15:54 Steve Small
Love that. Nice Don. And now everyone's favorite segment, fast facts.
00:16:05 Don Weinberger
So this is where we jump into common bio-sized claims about opioids and give them a seal of approval or debunk them quickly.
00:16:12 Steve Small
And first up, intranasal naloxone doses over 4 milligrams are more effective for opioid overdoses.
00:16:18 Don Weinberger
The verdict is rumor. 2024 study compared 8 milligrams versus 4 milligram intranasal naloxone found no significant differences in survival or number of doses administered, but higher withdrawal signs and symptoms with the 8 milligrams.
00:16:32 Steve Small
So more naloxone is not automatically better naloxone. Give repeat doses when needed, but don't assume the higher dose product improves routine outcomes.
00:16:42 Don Weinberger
Correct. Next claim is equianalgesic conversion tables are precise.
00:16:47 Steve Small
Verdict here is rumor with conditions. They are useful guides, but they are built on limited data, often single dose studies, which I was surprised to hear. And they do not account for patient specific factors such as organ function, genetics, tolerance, interactions, or what you're even rotating to.
00:17:04 Don Weinberger
So use your table and then use that brain, which inconveniently is not available as an app update.
00:17:10 Steve Small
Very true, Don. And our last claim here is that codeine is an effective option for cough.
00:17:16 Don Weinberger
The verdict is, evidence is mixed. Codeine has a long history of being an antitussive, anti-cough, but trials and reviews often fail to consistently show clear benefits over placebo for common acute cough. And CYP2D6 metabolism creates variability and safety concerns in certain patients.
00:17:33 Steve Small
Especially children, right? FDA and the American Academy of Pediatrics recommend against codeine cough suppressants in kids under 18.
00:17:41 Steve Small
And they're contraindicated in kids under 12, since risks such as overdose, dependence, and slower breathing outweigh codeine's benefits.
00:17:54 Don Weinberger
So notice the pattern? A lot of opioid myths start with a simple rule and fall apart when you look at the details.
00:18:00 Steve Small
Which means we're perfectly prepared for our final claim.
00:18:04 Don Weinberger
Yes we are. And this claim can cause real harm, if clinicians just treat it as an absolute.
00:18:11 Don Weinberger
And that claim is patients with opioid use disorder or OUD can't be treated with opioids for pain.
00:18:19 Steve Small
I'm glad we're tackling this, Don, because we get a lot of questions about this.
00:18:23 Don Weinberger
And we do. It's important to note here that patients with OUD still experience acute pain, surgical pain, trauma pain, cancer pain, and chronic pain.
00:18:33 Steve Small
Right. And I think this is where a lot of clinicians start feeling uncomfortable.
00:18:36 Steve Small
Nobody wants to undertreat severe pain, but nobody wants to trigger relapse, worsen misuse risk, or interfere with a patient's meds for opioid use disorder, MOUD, either. Meds like buprenorphine, methadone, naltrexone.
00:18:50 Don Weinberger
Exactly. And that's why simple rules, they don't work here. Quote, never use opioids is too simplistic. Quote, treat them exactly like everyone else is also too simplistic. These situations usually require thoughtful planning and coordination.
00:19:06 Steve Small
And you actually wrote an article about this recently, Don, on the August issues of Pharmacist Letter and Prescriber Insights. So what are some good tips to think about here?
00:19:14 Don Weinberger
Yeah, well, for mild to moderate pain, optimize those multimodal non-opioid analgesics first. You know, things like acetaminophen, Toradol, or nerve blocks if you're in the hospital.
00:19:28 Steve Small
And if non-opioids aren't enough?
00:19:31 Don Weinberger
Expect to add a short-acting full opioid agonist, things like hydromorphone, fentanyl, morphine, things like that.
00:19:41 Don Weinberger
Higher initial doses may be used to overcome receptor blockade and tolerance from those medications for opioid use disorder or MOUDs. And also methadone and buprenorphine are usually continued as those MOUDs.
00:19:54 Steve Small
And that makes it important to verify home doses directly with the patient or their treatment program because we know prescription drug monitoring program databases with your state may not reflect current dosing of those meds.
00:20:05 Don Weinberger
Excellent call out.
00:20:06 Don Weinberger
Yes.
00:20:07 Don Weinberger
And those MOUD regimens may be adjusted to double duty as analgesia, such as splitting daily methadone doses into 3 doses per day and buprenorphine split into giving doses every 6 to 8 hours.
00:20:20 Don Weinberger
Doing this can help utilize their short analgesic windows.
00:20:25 Don Weinberger
Going back to that claim, which is patients with opioid use disorder cannot be treated with opioids for pain.
00:20:30 Don Weinberger
The verdict is… Rumor.
00:20:38 Steve Small
So to be clear here, patients with opioid use disorder can be treated for pain.
00:20:42 Steve Small
And sometimes that includes using opioids, but it should be deliberate, coordinated, and risk aware.
00:20:49 Don Weinberger
Yeah, unfortunately, this is one of those rumors that can cause real patient harm when people believe it.
00:20:56 Steve Small
So don't use opioid use disorder as a reason to dismiss pain.
00:20:59 Steve Small
Use it as a reason to plan carefully.
00:21:01 Steve Small
If you work in a hospital, see if you have an addiction medicine team that you can collaborate with to design a safe plan.
00:21:07 Don Weinberger
Yeah, good call out, Steve.
00:21:08 Don Weinberger
And for community pharmacists, coordinate with the patient's MOUD prescriber when possible.
00:21:14 Don Weinberger
Use multimodal analgesia and document the goal and duration, monitor it closely, and avoid stigma in the language that you use.
00:21:23 Steve Small
All important steps. And for technicians, you can help by checking with the patient or their treatment program to see what their actual MOUD regimen is.
00:21:31 Steve Small
Prescription drug monitoring programs or those PDMPs we talked about aren't always current since regimens change frequently.
00:21:37 Don Weinberger
You know, we got a great FAQ, which is treatment of acute pain and opioid use disorder, to give you more tips on safe approaches in these complex situations.
00:21:47 Steve Small
That is a great and popular resource.
00:21:49 Steve Small
And in terms of our episode today, the bottom line truth is that opioids are not villains, heroes, or shortcuts.
00:21:55 Steve Small
They are high stakes tools. And the safest tool is 1 used deliberately.
00:22:00 Don Weinberger
Love that. So today's claims were different, but they all pointed to the same lesson.
00:22:05 Don Weinberger
Beware of absolutes. In opioid care, simple answers are often the most dangerous answers.
00:22:11 Steve Small
And that's why good clinicians don't rely on assumptions.
00:22:14 Steve Small
They rely on evidence, context, and careful patient-centered decision-making.
00:22:19 Steve Small
Now we've got you thinking, and hopefully not itching, claim CE credit and access evidence-based resources from pharmacist letter, pharmacy technicians letter, or prescriber insights.
00:22:31 Don Weinberger
If you're not yet a subscriber or want to upgrade, you can save 10% with our exclusive listener code, RVT1026 at checkout.
00:22:40 Don Weinberger
Easy link in the show notes.
00:22:42 Steve Small
And if you're already a subscriber, tap the claim credit link in the show notes or search your CE organizer for this episode.
00:22:50 Don Weinberger
All right, and now mailbag time.
00:22:53 Don Weinberger
We got an audience question from our previous laxative episode come through our rumor vs truth at trchealthcare.com e-mail.
00:23:02 Don Weinberger
And they asked us, is it true that polyethylene glycol needs to be separated from other meds?
00:23:07 Don Weinberger
And if so, by how long?
00:23:10 Steve Small
Good question.
00:23:11 Steve Small
And we had to sit and ponder this one.
00:23:14 Don Weinberger
Those puns came rolling back, which for a laxative question is either very fitting or very unfortunate.
00:23:21 Don Weinberger
If you're curious, just scroll your feed for the bonus mailbag and you'll find our full answer there.
00:23:27 Steve Small
And if you'd like to have your question about this opioid episode answered for our next bonus mailbag, whether it's about naloxone, itching, OUD, cough, or other rumors, send it in.
00:23:38 Don Weinberger
E-mail us at Rumor vs Truth at trchealthcare.com or send us fan mail right from the podcast show notes.
00:23:46 Don Weinberger
We also use your suggestions and feedback to plan our episodes.
00:23:49 Steve Small
And join us next time where we'll tackle unique claims about generic meds.
00:23:54 Don Weinberger
Yep, we'll see which claims are truly interchangeable or which ones come with very important exceptions.
00:24:00 Don Weinberger
So thank you for joining us on Rumor vs Truth, your trusted source for facts, where we dissect the evidence behind risky rumors and reveal those clinical truths.
00:24:10 Steve Small
We'll see you next time.
