Opioid Resource Center

Opioid Resource Center

Disclosures: Benjamin reports he received grant support from the NHLBI and MDA. Chow reports no relevant financial disclosures. Please see the full advisory statement for all other authors’ relevant financial disclosures.
August 19, 2021
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AHA: Seek opioid alternatives for management of pain in patients with CVD

Disclosures: Benjamin reports he received grant support from the NHLBI and MDA. Chow reports no relevant financial disclosures. Please see the full advisory statement for all other authors’ relevant financial disclosures.
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Greater use of opioid alternatives for the treatment of pain in patients with CVD and expanded public training in the recognition and treatment of overdose may stem the contemporary rise in opioid-related deaths, a committee wrote.

In an advisory statement published in Circulation, the American Heart Association partnered with experts in the fields of medicine, pharmacotherapy, research and federal regulations to develop recommendations and guidance for health care professionals and researchers in the setting of CV and brain health.

AHA: Seek opioid alternatives for management of pain in patients with CVD
AHA: Seek opioid alternatives for management of pain in patients with CVD. Data were derived from Chow SL, et al. Circulation. 2021;doi:10.1161/CIR.0000000000001007.

“Opioid abuse accelerated during the COVID-19 pandemic due to disruption of the illicit drug supply environment, more limited access to medications, and social isolation and depression related to pandemic safety measures,” Sheryl L. Chow, PharmD, FAHA, associate professor of pharmacy practice at Western University of Health Sciences, associate clinical professor of medicine at the University of California, Irvine, and chair of the advisory writing group, said in a press release. “Opioid overdose is now a leading cause of death for Americans 25 to 54 years of age, and opioid use disorder affects more than 2 million Americans.”

According to findings reported by the National Center for Health Statistics (NCHS), the age-adjusted mortality rate associated with drug overdoses in the U.S. increased from 6.1 per 100,000 people to 21.6 per 100,000 people from 1999 to 2019. This rate rose an additional 15.5% from December 2019 to June 2020, according to NCHS data.

Accompanying the rising prevalence of overdose-related mortality, one report found that two of every three overdose deaths were opioid-related.

Moreover, the opioid epidemic disproportionately affected adults aged 25 to 34 years (38.4 per 100,000), 35 to 44 years (39 per 100,000) and 45 to 54 years (37.7 per 100 000), according to one report.

“Opium contains alkaloids such as morphine and codeine that are ligands of the mu-opioid receptor and has been used for thousands of years for the medical management of pain,” the committee wrote. “In the cardiovascular and cerebrovascular systems, opioids and endogenous derivatives such as endorphins exert potent effects within the central and peripheral nervous systems to regulate blood pressure, heart rate and even thermogenesis in brown adipose tissue.”

According to the advisory, data suggest opioids that are commonly used for pain management may interfere with frequently used medical therapies for CVD and stroke.

Recommendations for opioid alternatives

The committee provided the following recommendations for physicians who are managing pain in patients with CVD:

  • Consider opioid alternatives such as acetaminophen, aspirin and nonacetylated salicylates for patients with musculoskeletal disease and CVD.
  • Routine use of morphine in the setting of ACS may reduce the therapeutic efficacy of P2Y12 antagonists.
  • When used in moderation, morphine may be useful in reducing acute pain and anxiety for patients who continue to experience pain despite alternative approaches.
  • Parenteral antiplatelet agents for ACS can be considered in the hospital setting when co-administered with morphine.
  • Further research in nonpharmacological pain treatment options is needed to identify ways to improve availability and access.

Guidance to improve management of opioid overdose

The writing committee also provided the following guidance for the acute management of opioid-related drug overdose:

  • Stakeholders should ensure that all public health education and training programs for suspected opioid overdose include instructions for calling 911, performing CPR with rescue breathing, use of an automated external defibrillator and administering naloxone.
  • Increase awareness and education on the prevention, screening and training of opioid overdose response for both health care professionals and patients.
Ivor J. Benjamin

“This advisory includes both immediate and long-term strategies to help mitigate the devastating intersection of opioid abuse and cardiovascular disease,” Ivor J. Benjamin, MD, FAHA, former president of the AHA, director of the cardiovascular center, co-director of the NIH T32 Postdoctoral Fellowship in Cardiovascular Sciences and professor of medicine at the Medical College of Wisconsin in Milwaukee, said in the release. “Together with our partners throughout public health, policy and government infrastructures, we can help support health care professionals and people in our communities more effectively avoid the preventable deaths caused by opioid use disorder and opioid overdose.”

Please see the full AHA advisory for complete details on its recommendations for addressing the opioid public health crises at a regulatory level, areas that require further research and suggestions for public health initiatives.

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