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Polypharmacy: A Clinician's Essential Guide

With the rapidly evolving landscape of pain management, treating patients with multiple chronic pain conditions and comorbidities has become increasingly challenging. It's crucial to use safe and evidence-based strategies to manage these patients effectively. This helps minimize serious risks like drug interactions, overdoses, misuse, substance use disorders, and even death.  

How common is polypharmacy in patients who use opioids?  

Polypharmacy, the use of multiple medications, is common among adults who use opioids. It increases the risk of drug-drug interactions (DDIs) and adverse drug events (ADEs) such as overdose. The more medications a patient takes, the higher the chance of DDIs.  

Key Findings From The Cytochrome P450 (CYP450) Study:  

  1. Prospective Cohort Study:  

  • Among older adults hospitalized and taking five or more medications, potential cytochrome P450 (CYP) mediated DDIs occurred at an 80% frequency.  

  • The probability of DDIs was 50% in patients taking five to nine medications and 100% in those taking 20 or more drugs.  

2. Medicare Part D Analysis:  

  • Patients using opioids filled an average of 52 prescriptions per year from nearly ten unique drug classes.  

  • 20% of these patients took more than ten concurrent medications.  

  • Opioid users had nearly two more comorbid conditions on average compared to non-users, often psychiatric (e.g., major depressive disorder, bipolar disorder), leading to central nervous system (CNS) polypharmacy ( use of three or more medications that have psychoactive characteristics).  

  • 75% of older patients with CNS polypharmacy were also opioid users, increasing risks of falls, cognitive impairment, accidental overdose, and death.  

3. Prevalence and Risks:  

  • 30% of patients using opioids are exposed to clinically significant drug interactions.  

  • Opioids are frequently involved in DDIs. A study found that 25% of pharmacist-identified pharmacokinetic drug interactions in medically complex, older patients with polypharmacy (nearly 16 medications per patient) involved opioid therapy.  

Implications for Clinicians: Managing patients with multiple pain conditions and comorbidities is challenging. Effective and safe treatment requires careful consideration to avoid medication overuse, misuse, and abuse while also mitigating the risks of polypharmacy and DDIs.  

What are the current strategies to protect against polypharmacy?  

To protect patients from the impact of polypharmacy, several strategies have been implemented:  

  1. Boxed warnings (formerly known as Black Box Warnings): Issued by the FDA, these warnings alert clinicians to the serious risks associated with certain medications, including potential drug-drug interactions (DDIs).  

2. Screening Tools:  

3. Clinical Decision Support Systems (CDSS): These systems offer a promising option to help clinicians identify opioid-associated DDIs. However, current technology is still fallible, and clinicians may miss critical DDIs, particularly in patients with polypharmacy.  

The unmet need for continuing medical education on polypharmacy  

Despite widespread use in chronic pain management, opioids are less effective than non-opioid alternatives and pose severe health risks, including overdose and mortality. Evidence highlights the prevalence of opioid-related drug interactions, which are often overlooked in clinical settings. Healthcare providers must understand the complexities of polypharmacy and opioid-related interactions, as they significantly impact patient care and safety. Recognizing and mitigating risks associated with opioid-involved drug interactions is essential for balancing treatment efficacy and safety.  

If you’re ready to learn more about polypharmacy, the following courses will be offered at PAINWeek 2024, Sept. 3-6, in Las Vegas, to help healthcare providers like you grasp the complexities of polypharmacy and opioid-related interactions.  

To learn more and register for PAINWeek 2024, click here. 

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