Conolidine: A Novel Plant Extract for Chronic Pain

: Pain, the most common symptom reported among patients in the primary care setting, is complex to manage. Opioids are among the most potent analgesics agents for managing pain. Since the mid-1990s, the number of opioid prescriptions for the management of chronic non-cancer pain (CNCP) has increased by more than 400%, and this increased availability has significantly contributed to opioid diversion, overdose, tolerance, dependence, and addiction. Despite the questionable effectiveness of opioids in managing CNCP and their high rates of side effects, the absence of available alternative medications and their clinical limitations and slower onset of action has led to an overreliance on opioids. Conolidine is an indole alkaloid derived from the bark of the tropical flowering shrub Tabernaemontana divaricate used in traditional Chinese, Ayurvedic, and Thai medicine. Conolidine could represent the beginning of a new era of chronic pain management. It is now being investigated for its effects on the atypical chemokine receptor (ACK3). In a rat model, it was found that a competitor molecule binding to ACKR3 resulted in inhibition of ACKR3’s inhibitory activity, causing an overall increase in opiate receptor activity. Although the identification of conolidine as a potential novel analgesic agent provides an additional avenue to address the opioid crisis and manage CNCP, further studies are necessary to understand its mechanism of action and utility and efficacy in managing CNCP.

Opioid Prescribing Risk Management Opportunities for the Advance Nurse Practitioners

All clinicians are ethically obliged to prescribe responsibly and cautiously to diminish the potential for opioid diversion and to help minimize the growth of the current opioid abuse epidemic. Advance nurse practitioners should establish procedures to better control and limit opioid prescription and develop analgesic regimens to treat pain. The main purpose and goal for this review is to present data congruent with clinical, medical, and legal reports for allowing an appreciation of the possibility of the risk assumed when ordering and prescribing opioids within our podiatry profession. First, the concept and process of risk management as illustrated using a root cause analysis approach will be introduced as well as applying these principles specifically to opioid prescribing will be presented. Then, several examples found in both medical and legal literature documenting the reasons for opioid prescription risk will be presented. Finally, mitigating strategies for safe opioid prescribing will be presented so that mitigation of opioid harm can be possible and realized by the advance nurse practitioner

Opioid therapy

Opioid use disorder (OUD) is a prevalent condition associated with substantial morbidity, mortality, and healthcare utilization. Prescribers must rely on multiple tools and tactics to help reduce the risk of OUD. These include identification of risk factors for OUD and risk stratification, which must be individualized for each patient. Opioid diversion must be considered distinct from OUD and it has some unique risk factors. Aberrant drug-related behaviours may be observed in those taking opioids and may or may not suggest OUD; risk factors for OUD are dynamic. However, many aberrant drug-related behaviours may be harmless or misinterpreted. A variety of validated risk assessment tools are available to better quantify risk for OUD. An important factor in thwarting OUD remains patient and prescriber education as well as specialized resources such as patient–prescriber agreements, abuse-deterrent formulations of opioids, urine drug screens, and prescription drug monitoring programmes. There is no single, easy way to reduce OUD; instead, prescribers must be aware and make use of the many tools at their disposal to better pre-emptively identify those at elevated risk for OUD and to offer help to those who develop OUD over the course of prescribed opioid therapy.

Providing Information Improved Adequate Storage and Disposal of Opioids by Bereaved Family Caregivers

Context: Poor understanding regarding the safe use, secure storage, and adequate disposal of unused opioids may contribute to the opioid epidemic. It is unclear what happens to unused opioids in the households of deceased cancer patients. Objectives: Our aim was to investigate the patterns of use, storage, and disposal of unused opioids among families of deceased cancer patients. Methods: A questionnaire was administered to families of deceased cancer patients. Questions were related to the use, storage, and disposal of opioids prescribed to their deceased family member. Results: Completed questionnaires were received from the families of 240 patients. Of these, 129 (53.8%) and 99 (41.3%) participants were aware of the danger of diversion and need for safe disposal, respectively. One (0.4%) participant reported diversion. In total, 177 participants (73.8%) stored opioids securely, 6 (2.5%) had unused opioids at home, and 142 (59.2%) returned unused opioids to medical health providers. Knowledge of safe opioid disposal increased the rate of returning opioids to medical health providers (84.8% vs. 53.2%; p < 0.001) and decreased the rate of participant disposal (13.3% vs. 37.6%; p < 0.001). Prior knowledge of the risks of opioid diversion was associated with storing opioids securely (91.9% vs. 80.7%; p = 0.028). Conclusion: Most families of deceased cancer patients follow safe use, secure storage, and adequate disposal of prescribed opioids. Awareness of opioid diversion and the need for adequate disposal increased the prevalence of safe practices.

Prescription Drug Monitoring Programs and Prescription Opioid–Related Outcomes in the United States

Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments’ response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid–related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the United States is associated with changes in 4 prescription opioid–related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance-use disorders, and opioid-related deaths. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All 3 studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance-use disorders domain, 7 of 8 studies found associations with prescription opioid–related outcomes. Four of 8 studies in the opioid-related deaths domain reported reduced mortality rates. Despite the mixed findings, emerging evidence supports that the implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance-use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance-use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time.