Some patients skip telling their doctors about the drugs and medications they are consuming. A new study shows that these patients are at a greater risk of unpleasant and sometimes dangerous drug-drug interactions as well as addictions.
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The study was published in the latest issue of The Journal of the American Osteopathic Association. The study is titled, “Role of opioid-involved drug interactions in chronic pain management”.
The study looked at the common omissions people made in disclosure of the medications they are on. The team explains that around one in three individuals prescribed medications can have these drug-drug interactions. They added that these interactions and their aftermath is seldom reported. Some of the drugs can affect the way the body handles and metabolizes opioids, the authors of the study wrote. This can lead to misuse, overdose and addictions to the drugs, they wrote.
The team writes, “A devastating consequence of the surge in opioid prescriptions over the past decade in the United States has been a parallel rise in opioid abuse, misuse, and death…In 2016, more than 2.1 million people had an opioid use disorder. That year, a reported 11.5 million persons misused prescription opioids, particularly hydrocodone (6.9 million), oxycodone (3.9 million), codeine (2.8 million), and tramadol (1.6 million). From 1999 to 2014, there were more than 165,000 reports of opioid-related overdose deaths. In 2015, 15,281 persons died of overdoses involving prescription opioids.”
They added, “Successful management of chronic pain requires treating the whole person and achieving a fine balance between opioid-related risks and benefits. The individualistic nature of drug interactions has the potential to affect the risk-benefit ratio.” The team wrote, “A growing body of evidence suggests that opioids are involved in significant drug interactions that often go unrecognized in clinical practice. Understanding opioid-involved drug interactions is of great practical importance for all health care professionals caring for patients with chronic pain.”
Kevin Bain, MPH, PharmD, co-founder and medical director at Biophilia Partners, and the first author of the study said, “The concern we have is that patients may not get the proper amount of pain relief due to an undetected interaction with some other medication they're taking. That can lead to them taking higher doses of their prescribed opioid and more frequently, which over time can lead to a substance use disorder or even an overdose.”
Explaining about the mechanism behind the opioid-drug interaction, the team wrote, “The cytochrome P450 (CYP) system is the principal phase I metabolic pathway for most drugs… Substrates sharing the same isoenzyme interact such that the stronger affinity substrate (or perpetrator drug) competitively inhibits the weaker affinity substrate (or victim drug)…This type of competitive inhibition can be overcome by increasing the dose of the victim drug to surpass the dose of the perpetrator drug. However, higher opioid doses pose greater risks for opioid use disorders and overdoses.”
Bain added that the remedy could be consultation with a pharmacist before prescription of opioids by a physician. A detailed history of all the drugs that the patient is on would help determine the effects of the opioid prescription, he added. He also advised that patients should also volunteer to report all the medications they are on before receiving an opioid prescription.
Bain warned that some of the common medications that could interact with the opioids prescribed include antidepressant medications and antipsychotic medications. Others include drugs for heart disease especially those for treatment of abnormal heart rhythms and high blood pressure.
The authors of the study point out several habits patients have when it comes to consuming medications, that could interfere with opioid use. For example, they wrote, most patients take all the prescribed medications at once to be sure that none are forgotten. Bain explained that this was one of the major reasons that could contribute to drug interactions. His advice was that there should an interval between the intake of the drugs. Codeine and tramadol both for example can lead to drug interactions, he said. Bain also said that prescription that does not contain opioids could be modified so that the risk of interactions could be minimized. He said, “The possible combinations that might result in a drug interaction are vast. The best approach is for physicians and patients to partner closely with a pharmacist who can advise on potential complications, especially at the start of an opioid prescription.”
One of the most important recommendations by the authors of the paper says that patients should not modify or alter the dose or frequency of their prescribed drugs without consultation. Bain concluded that there should be a clear communication between the physician and the patient to ensure reducing the interactions caused by opioids and other drugs.
Bain KT, Knowlton CH. Role of Opioid-Involved Drug Interactions in Chronic Pain Management. J Am Osteopath Assoc 2019;119(12):839–847. doi: https://doi.org/10.7556/jaoa.2019.136.