Category: Opioids

There are three prevention strategies to be applied to address the development of the current opioid crisis that includes primary, secondary, and tertiary prevention. Primary prevention strategies are based on the prevention of opioid abuse through improving prescription procedures as clinicians need to assess a variety of factors and risks before prescribing opioids to patients. The effective evaluation of possible risks of the development of drug addiction is obligatory. In this situation, the focus should be on proposing non-opioid analgesics as alternatives for patients (Kolodny et al., 2015). The non-medical use of opioids can be prevented by asking for only legitimate prescriptions in the pharmacy.

Secondary prevention in the context of the opioid crisis is related to screening individuals’ health conditions. The focus is on treating opioid-addicted people to prevent complications and decrease the risk of overdosing. Much attention should be paid to educating community members regarding the early identification of opioid abuse (Kolodny et al., 2015; McAnally, 2018). Furthermore, clinicians need to pay more attention to screening patients regarding the necessity of continuing opioid therapy and providing prescriptions for refills.

In the context of tertiary prevention, it is necessary to promote therapeutic approaches and rehabilitation required for individuals addicted to opioids. Therapies can be prescribed depending on the results of multidimensional assessments of potential risks because many factors need to be taken into consideration. The purpose is to prevent drug abduction among treated patients and overcome the risks of overdosing. At this stage, it is necessary to apply substitution therapies supported by psychosocial therapy to promote positive outcomes of the treatment (Kolodny et al., 2015; McAnally, 2018). Clinicians are expected to facilitate individuals’ recovery from opioid addiction in the context of tertiary prevention strategies.

References

Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36, 559-574.

McAnally, H. B. (2018). Addressing host factors: Primary, secondary, and tertiary prevention of opioid dependence. In H. B. McAnally (Ed.), Opioid dependence (pp. 265-290). Cham, Switzerland: Springer.

Introduction

Opioids are classified as a classification of drugs that are used to suppress pain through binding of the Opioid receptors which form are located the gastrointestinal channel and the central nervous system. The opioid receptors in these two organs transmit both the positive outcomes and the negative effects of these substances. The analgesic effect of Opioid substances is achieved through decreasing the levels of pain detection; boosting the ability to tolerate pain and reducing the reaction to the perception of pain. By imposing these three effects these substances help reduce and; or relieve the levels of pain experienced by individuals. (Campbell, 2003)

The negative effects of opioids include constipation; respiratory difficulties and feelings of being sedated. Other effects of the use of Opioid substances include cough repression that can be an indication of either Opioid substance use or an unexpected outcome after administration. Opioid administration can also lead to physical reliance that brings about withdrawal syndrome after discontinuation; and feelings of Euphoria. Further the over dosage of these drugs is capable of bringing about death among other adverse effects. (Beers & Robert, 2002)

The focus of this work is to state and explain the grouping of Opioid drugs based on the chemical and pharmacological grouping. The drugs in question will be analyzed based on their chemical classes, and characteristic features like acid-base properties; structural features; solubility; polarity; ionization properties; partition and metabolism rate and channels. These include Fentanyl C₂₂H₂₈N₂O ; Methadone C₂₁H₂₇NO; Loperamide C₁₈H₂₁NO₃ ; Propoxyphene C₂₂H₂₉NO₂; Naloxone C₁₉H₂₁NO₄; and Pentazocine. (Kenneth, 2002)

Drug classification, chemical grouping and characteristics

When looking at the classification of opioids; six classes are distinctive and these include the endogenous opioids that are formed naturally by and within the body. An example of these is enkephalins. Another classification of opioids is the semis-synthetic that are formed from the use of natural opiates and an example of these is the hydromorphone. The other classification of these substances is the fully synthetic opioids such as pethidine; and the other classification is that of natural opiates that exist naturally in the resin of the opium poppy. (Beers & Robert, 2002)

As discussed earlier the main aim of these drugs is to influence the working of receptors that detect and communicate the effect of pain to the brain. Further drugs are referred to as acidic when they dissolve to donate a proton or basic when they donate at least one electron that is neutralized by a proton. However the drugs that exist in non-acidic or basic functional groupings are given the name non-electrolytes. In this sense it can be noted that the drugs that are basic like Methadone that have a higher pKa value are more likely to ionization as they are strong bases. The acidic surroundings needed for the ionization process to take place include the stomach. (Campbell, 2003)

The absorption scheme and channel for the different Opioid drugs is however, dictated by the method or area of administration used. These administration methods include: Oral administration; rectal administration; intramuscular administration and intravenous administration. The pathways used for the absorption of the different Opioids are common and one is shown in the diagram.

Drug Metabolism factors

After the reaction or absorption of drugs is when the metabolism rate of a drug is observed and this is where lipophilic compounds are converted into regular polar products. This rate is used in determining the intensity and duration of the drug on the body, and is mainly dictated by the ability of the liver to absorb the drug through chemical reactions. (Kenneth, 2002)

Acid-base properties

Drug review

Fentanyl

The chemical formula of its molecules is represented in figure below.

The molecular mass is 336.47 g/mol. This drug is used on cancer patients with intensive pain that is not addressed by the regular narcotic therapy. This drug works through acting on the Opioid mu-receptors which are located in the brain and the spinal cord. Its primary medical use is for analgesia or sedation through increasing the individuals’ tolerance to pain and the perception of it. It also does work through alteration of mood; drowsiness; or causing dysphoria. Fentanyl works through its conversion to morphine where opioids shut N-type run calcium communication (OP2-receptive agonist) and open calcium-dependent internally correcting potassium channels (OP3 & OP1 receptive agonist). This brings about hyper polarization thus reduced neuronal excitability. (Compton & Athanasos, 2003)

On the question of absorption Fentanyl has a bioavailability of 92% when administered transdermally and 50% when administered buccally.This drug is metabolized mainly through human cytochrome P450 3A4 isoenzyme structure and has a half-life ranging from 3-12 hours. The drug normally exists in a solid state and has a water solubility of 200mg/l. (Kenneth, 2002)

On the area of conjugate acid-base pairing, Fentanyl being a weak acid reacts as an H+ ion donor thus forming a conjugate base. Fentanyl hydrolysis led to the formation of despropionylfentanyl and alkyl hydroxylation led to the formation of hydroxyfentanyl. Fentanyl ionization takes place through its donation of an H+ particle depending on the receptor characteristics that are either acidic or basic. This process further leads to neutralization when the reacting agents are basic and this leads to the formation of a salt and water. (Beers & Robert, 2002)

Methadone

The chemical formula for the drugs molecule is shown above. This drug as a hydrochloride and primarily acts like a mu-pied agonist and has similar use as that of morphine except that it also has a restraining effect on cough centre like the one associated with fatal lung cancer. It is also used as treatment for dependence on opioid drugs though lengthened use of it may cause the same. It has an average molecular weight of 309.44g/mol and exists in solid form and has a water solubility of around 03 mg/ml. This drug is used for relief of severe pain; and detoxification management of narcotic addictions but is more active and toxic than morphine. (Kenneth, 2002)

Methadone works through acting as an antagonist at the N-methyl-D-aspartate receptor. The absorption of methadone following oral administration varies between 36 and 100%. In cases of over dosage it may lead to death; circulatory failure; cardiac arrest and apnea. On biotransformation cytochrome P450 enzymes convert methadone to EDDP and other dormant metabolites that are excreted through the urinary system. This drug has a half-life of between 24-36 hours and works by acting on the target areas that include the mu-opioid receptor; glutamate receptor subunit 3A; and the neuronal receptor subunit alpha-10. (Compton & Athanasos, 2003)

On the area of conjugate acid-base pairing; Methadone being weak acid and possessing weak basic traits either reacts through donating a H+ ion or an A- ion forming a conjugate solution. Methadone hydrolysis is done using Tartaric acid in an acetone /water mixture forming dextro-methadone; levotartate and levo-methadone. Methadone ionization takes place through either the positive ion donation H+ or the negative functional group depending on the receptor characteristics that either accept or donate conjugating functional groups. This process brings about neutralization that leads to the formation of a salt and water. (Beers & Robert, 2002)

Loperamide

The chemical formula for the molecule is shown below.

This drug is a long duration antidiarrheals though not significantly absorbed from the gut. It however has no impact on the adrenergic structure or the nervous network but may be used to antagonize histamine and to alter acetylcholine release. It has a molecular mass of 476.22 g/mol; exists in solid form and has slight water solubility of 04mg/ml. This drug is used for the treatment of diarrhea associated with inflammation of the bowels or gastroenteritis. Loperamide is an opioid receptor agonist that acts on the mu-opioid receptors within the large intestine. It does not affect the central nervous system but rather works by affecting the muscle system within the intestinal walls. By this process it increases fluid absorption; reduces colonic mass loss and restrains the gastrocolic reflex. In practical working it is a non-selective calcium blocker through binding to the mu-receptors; calmodulin and the NMDA receptors. (Compton & Athanasos, 2003)

On absorption, it’s not significantly absorbed from the gut; has a protein binding capability of 97% and overdose symptoms like constipation and nausea. This drug has a half-life of 9.1 -14.4 hours and is metabolized by the enzyme cytochrome P450 3A4 (CYP3A4) (Kenneth, 2002)

On the area of conjugate acid-base pairing; Loperamide being a weak acid reacts donating an H+ ion to form a conjugate base. Loperamide hydrolysis id done using carboxylesterases to form fluorouracil; and the ionization process takes place through its donation of an H+ ion leading to neutralization that forms a salt and water solution. (Beers & Robert, 2002)

Propoxyphene

The molecule of this drug has the above chemical formula.

This drug works through the analgesic effect of the dextro-isomer and the antitussive effect of the levo-isomer. The molecular weight of this drug is 339.47; exists in solid form and has an experimental water solubility of 19.6 mg/l. This drug works through binding to the opiate receptors within the nervous structure leading to reduced pain stimuli perception. This drug is a weak agonist that works by acting on the OP receptors especially theOP3 that are united with the G-protein receptors to function as modulators. By binding the opiate the exchange of GTP for GDP on the G protein complex is stimulated and further there is production of insulin; vasopressin and glucagons. This results to the closure of OP2 receptor agonists and opening of OP3 and OP1 agonists leading to overall hyperpolarization that suppresses neuronal excitability. The negative effects of this drug include respiratory depression; pulmonary edema and circulatory collapse among others. The half-life of reaction for this drug is 6-12 hours and is usually found in solid form. (Campbell, 2003)

On the area of conjugate acid-base pairing; Propoxyphene being a weak acid reacts to donate an H+ ion to form a conjugate solution. Propoxyphene hydrolysis is done using an acidic solution leading to the formation of a metabolically usable compound. Propoxyphene ionization takes place through the donation of an H+ ion to bond with the conjugating functional group leading to neutralization that forms salt and water. (Beers & Robert, 2002)

Naloxone

The chemical formula for the molecule of this drug is shown in the diagram:

This drug works through affecting the mu; kappa and delta opioid receptors; has a molecular weight of 327.37 g/mol and exists in solid form with solubility 5.64e. This drug is used for the complete or partial reversal of the negative effects of natural and synthetic narcotics; these may take the form of respiratory depressions; depression and hypotension. On the area of action; Naloxone works through antagonizing the opioid effects through struggling for the same receptor zones mainly the mu-receptor. However research has lately found out that Naloxone has binding effects on the other receptors like gamma and kappa. On the question of absorption, Naloxone is best absorbed when administered through intramuscular injection. Naloxone undergoes hepatic biotransformation and has a half-life of reactivity ranging between 30-81 minutes. (Campbell, 2003) On the area of conjugate acid-base pairing; Naloxone which is a weak base reacts through donation of an A- ion to for a conjugate solution. Naloxone hydrolysis through the reduction of opioid activity led to the formation of casein formula.

The ionization of this drug takes place through the donation of the A + ion to the reacting functional group that brings about neutralization leading to the formation of water and a salt solution. (Beers & Robert, 2002)

Pentazocycine

This drug has the molecular chemical structure shown below.

It’s the mixed agonist-antagonist pain reliever to be manufactured having an agonist function at the kappa and sigma opioid receptors; and a weak antagonist action at the mu-receptor. It has a molecular weight of 285.42 g/mol; exists in solid form and a water solubility of 1.22e. This drug is found to work significantly on administration after 15-30 minutes and is orally administered. The action duration is usually 3hours or longer and can be used to antagonize the analgesic effects of meperidine and morphine. It’s also found to be capable of partially reversing the behavioral depression; cardiovascular and respiratory difficulties induced by other Opioids like morphine. (Campbell, 2003)

Pentazocycine works through competing for receptor regions especially the mu receptor thus antagonizing the opioid effects of other drugs. This drug is best absorbed from the gastro-intestinal tract; undergoes hepatic biotransformation and has a half-life of reaction ranging from 2-3 hours. On the area of conjugate acid-base pairing; Pentazocycene being a weak acid reacts through donating an H+ ion for a conjugate solution. Pentazocycene hydrolysis is done using hydrochloric acid to make glycerinate; while the ionization of it takes place through donating the H+ ion to the conjugating agent leading to neutralization that results to the formation of a salt and water. (Beers & Robert, 2002)

The explanation as to why effects of opioids like methadone effects last longer include the fact that its lipid solubility is quite high; the dependence incidence of patients is slow; and methadone metabolism is slow. This is the case due to the complex basic molecular composition of methadone and its ability to react within the organism for an extensive period of time ranging from 24 to 48. Another cause for this working of methadone is the genetic variability that is observed in the production of the associated enzymes. The fact that methadone is a soluble salt also makes the administration of this substance much easier as it is administered orally inform of a solution, and this helps improve the rate of intake as compared to other forms of administration like the tablet or the pill. This is the case because; through oral administration the drug goes directly into the gastro-intestinal tract that forms a major opioid reception region. (Campbell, 2003)

Most Opioids have the following molecular components: ditrideuteriomethylamino; dimethylamine hydrochloride; diphenylheptan one hydrochloride and as a result shows rather different physical and chemical properties when in different forms e.g. in solution, or solid. Methadone has basic properties; hydrophilic properties; and is depressive on metabolic processes. The fact that most opioids are acidic gives the idea that they most likely possess different ionization rates in different individuals depending on their genetic characteristics. These variations depend on the substances or drugs the individual had taken before the administration of the latter Opioid. (Campbell, 2003)

One of the adverse effects of Opioids especially Methadone is that it results to urinating difficulties and this can be used as a fact to justify the negative reactions of this drug in the human body that bring about dehydration. Methadone is often taken orally in the form of a solution; pill, or tablet and therefore this can be used to argue out that this drug has the property of being soluble in certain liquids. (Compton & Athanasos, 2003)

Alkylation is the exchange of an Alkyl group in the form of an akyl carbocation, carbine or carbanion from one molecule to the other. The Alkyl groups’ organic combination may take the form of methylation.The combination of one opioid with other opioids gives the justification that this process is involved in the chemical combining of the two compounds. Acylation is a chemical process through which an Acyl group is added to a compound. The compound that gives out the Acyl group is referred to as the Acylating agent and this process can be attributed to the compound combination of one opioid drug with other chemical compounds during medical applications. Phosphorylation is the adding up of a phosphate set to an organic molecule or a protein. This is a process used to turn many protein enzymes on and off that has the effect of stopping the development processes of diseases like diabetes and cancer. This chemical process maybe involved in the reaction of opioids depending on the donor properties of the reacting agents that are combining. (Compton & Athanasos, 2003)

Opioids being multiuse chemical compound have the capability for combining with other compounds on the basis of electrostatic attraction, and exchange as a result of the presence of charged groups within its compound form. Ionic bonding is the chemical bond that involves a metal and a nonmetal ion or polyatomic ions through electrostatic attraction of differently charged ions. (Kenneth, 2002)

The structural features of Opioids are varied as discussed previously. Opioids have the capability of making varied chemical combination when subjected to different reaction agents or physical processes. These variations in chemical structure include isomers that will have the same molecular formula but with different arrangement of the atoms forming the compound. The name given to the optical isomers of opioids is as a result of their respective effect on polarized light and these substances are referred to as enantiomers as they exist as two isomers. Diastereomers on the other hand occur, when two or more stereoisomers of a chemical compound have differences of structure at one or more ends therefore giving rise to two different configurations thus different stereoisomers. (Wilson, Caroline & Margaret 1999)

Talking of the relationship between the effects of molecular properties on the biopharmaceutical features of drugs can be explained using the common administration of drugs that is oral. This can be seen from the fact that oral bioavailability is one of the most essential considerations for the proper fashioning of bioactive molecules. As a result, poor oral bioavailability reduces drug working capabilities as it leads to high inter- and intra-patient variability. As seen in the case of Methadone the high lipid solubility; the ability to dissolve and the slow metabolism rate affect the drug delivery of this drug, in that the lipid solubility enables it to be delivered to the different parts of the body and react with different target compounds. The slow metabolism rate that is also a molecular effect of the compound makes the reaction process more far-reaching and capable of suppressing pain for longer time in the case of analgesics. The high absorption rate affects the absorption levels of the drug and therefore has a direct effect on the transport and delivery to the different parts of the body. (Wilson, Caroline & Margaret 1999)

Drug receptors are molecules involved in the chemical transmission between and within cells and are found within the cytoplasm or the cell membrane. The level of interaction between the drug molecules and the receptors dictates the level of transmission of drugs between and within different cells. This has direct effect on the level of performance of a drug and is dictated by the Molecular composition and compatibility with the cells. (Kenneth, 2002)

The bio-transformation pathways of drugs is affected by; tissue localization of the metabolic processes; metabolic interactions; individual variability and polymorphism. However these factors affect the transmission pathways based on the chemical and molecular properties of the drugs, where those that are favorable to the process in terms of molecular composition are transmitted faster and better. (Compton & Athanasos, 2003)

The factors affecting drug metabolism include; age; pharmacogenetics; nutrition; sex; enterohepatic circulation and intestinal features. In this case metabolism is slower in elderly individuals than in ordinary adults among other factors. As a factor, enzyme induction or inhibition can also be attributed to different levels of drug metabolism as they either slow or increase the rate of metabolism. In the drug metabolism enzyme system within the liver cell, injury occurs that is said to bring about hepatic metabolism but in this case its not considered. The strategies employed in managing drug metabolism include; reducing or increasing the level of intake of the drug; the use of a second messenger cell signal system like the hormone insulin that controls glucose levels; and injection of hormonal balancing strategies that help balance the levels of secretion of body fluids. (Campbell, 2003)

Pharmacological activity of body molecules is an explanation of the adverse or beneficial effects of drugs’ active ingredients that are however influenced by the other constituents of the drug. These pharmacological activities can show in terms of toxicity; stimulated body fluid formation and counteractive symptoms like allergies and dehydration. (Beers & Robert, 2002)

Conclusion

However it should understood that the use of Opioids as pain depressors or for other uses has both positive and negative outcomes. However the addiction; withdrawal syndrome or negative effects of one Opioid can be overcome through the use of a different one.

Reference list

Beers, M., & Robert, B. (2002). The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories..

Campbell, D. (2003) “Parenteral Opioids for Labor Analgesia.” Clinical Obstetrics and Gynecology 46, 616-622.

Compton, P., & Athanasos, P. (2003) “Chronic Pain, Substance Abuse and Addiction.” Nursing Clinics of North America 38, 525-537.

Kenneth, R. (2002).The Best Alternative Medicine, Part I: Western Herbal Medicine. New York: Simon and Schuster.

Wilson, B., Carolyn, L., & Margaret, T. (1999).Nurses Drug Guide 2000.Stamford, CT: Appleton and Lange.

Opioid misuse is considered to be a major health problem in the US and a leading cause of injury-related death. The rate of overdose death related to the use of opioids has drastically increased over the last couple of decades (Centers for Disease Control and Prevention, 2019). Opioid-related overdose death rates and prescribing rates vary widely across different states. West Virginia’s opioid-related overdose death rate of 43.40 was one of the highest in the US in 2016 (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2018, p. 1422). This is threefold higher than the national opioid-related overdose death rate of 13.3 in 2016 with a total of 42,249 drug overdose deaths (Scholl et al., 2018, p. 1422).

In turn, West Virginia’s drug overdose death rate involving prescription opioids is 19.7, whereas the national average is just 5.2. In 2015, West Virginia healthcare providers wrote 110 opioid prescriptions for 100 persons, compared to the average US rate of 70.6 prescriptions (Centers for Disease Control and Prevention, 2018, para. 8). Alarming rates for West Virginia highlight the need to mobilize a national and state response to the opioid epidemic.

Three types of prevention interventions have been identified in order to decrease the alarming opioid crisis with its staggering death rates. Primary prevention intervention focuses on opioid misuse prevention before it even occurs. A good example of such an intervention is dissemination and implementation of prevention programs that promote safe storage and disposal of opioids. It is assumed that prevention programs offered to teenagers and adolescents can effectively reduce the misuse of opioids in the selected population. These programs can be delivered in various settings and tailored to the attributes of specific communities. This intervention may be of particular importance to young people as individuals usually initiate drugs misuse when they are under the age of 18.

Secondary prevention intervention that could be considered is screening for opioid misuse. Routine screening for drug misuse using the opioid-risk tools can assess clinical risk for opioid abuse among people who are prescribed opioids. It may be assumed that screening can reduce opioid-related overdose death rates and address opioid prescription rates. Tertiary prevention intervention relates to the specific intervention that reduces harm or consequences of opioid misuse for individuals who already have a drug misuse disorder. An example of such an intervention may be the treatment of opioid use disorders and the provision of naloxone to prevent opioid-related overdose death.

The evidence-based strategy that could effectively reduce provider opioid prescription rates is the prescription drug monitoring programs (PDMPs). PDMPs are electronic databases that collect, analyze, and monitor prescriptions written to individuals on a state level. Pharmacies and dispensing practitioners submit the data to the PDMPs, and healthcare providers can access them to see patients’ prescribing histories.

Policies may be implemented to require that healthcare providers check their state PDMPs to inform their prescribing decisions. Thus, the main stakeholders charged with addressing the opioid crisis in my community are pharmacists, healthcare providers, and dispensing practitioners. There is evidence that the implementation of such intervention can improve opioid prescribing and protect patients who are at risk (Bao et al., 2016). Apart from reducing the use of multiple healthcare providers, the implementation of PDMPs can reduce opioid-related overdose death rates. It is worth mentioning that PDMPs are active databases that can be utilized by the health department to plan and evaluate interventions.

References

Bao, Y., Pan, Y., Taylor, A., Radakrishnan, S., Luo, F., Pincus, H. A., & Schackman, B. R. (2016). Prescription drug monitoring programs are associated with sustained reductions in opioid prescribing by physicians. Health Affairs, 35(6), 1045–1051.

Centers for Disease Control and Prevention. (2018). U.S. opioid prescribing rate maps. Web.

Centers for Disease Control and Prevention. (2019). CDC’s response to the opioid overdose epidemic. Web.

Scholl, L., Seth, P., Kariisa, M., Wilson, N., & Baldwin, G. (2018). Drug and opioid-involved overdose deaths — United States, 2013–2017. Morbidity and Mortality Weekly Report, 67(5152), 1419–1427.

The assigned case describes a patient with a history of substance abuse who was treated by EMS following an opioid overdose. The patient complained of burning pain in his hip and forearm. Upon examination, these areas revealed a large amount of necrotic tissue. The patient also had hyperkalemia with a serum potassium level of 6.9m Eq/L. The symptoms described in the case suggest that the patient has rhabdomyolysis.

This condition involves the rapid dissolution of skeletal muscle due to damage or injury (Torres et al., 2015). It is potentially life-threatening as it leads to ” the release of cell components like myoglobin, creatine kinase (CK), lactate dehydrogenase and potassium into circulation” (Stahl, Rastelli, & Schoser, 2020, p. 877).

Drug use is among the causes of the development of rhabdomyolysis. However, the condition is tied to various other causes, including traumatic injury, infections, muscle ischemia, metabolic, and genetic disorders (Torres et al., 2015). Genetic factors that contribute to the development of rhabdomyolysis include metabolic muscle disorders, mitochondrial disorders, muscular dystrophies, and conditions impairing intramuscular calcium release and excitation-contraction coupling (Scalco et al., 2015). Hence, genetics plays a role in the development of rhabdomyolysis because certain genetic illnesses can increase the patient’s risk of rhabdomyolysis and contribute to its development.

The patient’s symptoms are associated with opioid overdose, as well as with rhabdomyolysis. On the one hand, opioid overdose caused depression of breathing, leading to unconsciousness, which are both signs of the condition (Substance Abuse and Mental Health Services Administration, 2018).

On the other hand, rhabdomyolysis was associated with burning pain in the extremities since myalgia, muscle weakness, and dark urine are the classic clinical triad of rhabdomyolysis (Stahl, Rastelli, & Schoser, 2020). Myalgia, in this case, was caused by the destruction of muscle tissue in the area and the release of cell components into the bloodstream.

As part of EMS treatment, naloxone was administered, causing the patient to become responsive again. This physiologic response to the stimulus is tied to the effect that naloxone has on the body following an opioid overdose. Naloxone reverses the impact of opioids on the body, thus resolving respiratory depression and restoring breathing and consciousness (SAMHSA, 2018). The cells involved in this process are nerve cells that contain opioid receptors. Naloxone displaces opioids from these receptors, thus reversing its effect on the body (SAMHSA, 2018). For this reason, treatment with naloxone is appropriate for all cases of an opioid overdose.

Based on scholarly evidence and discussion, the response of EMS was appropriate to the situation. The paramedics administered naloxone to restore breathing and consciousness in the patient, but they did not assess him for rhabdomyolysis at first since he was unresponsive and could not describe the symptoms. The response to complaints about burning pain in the muscles would have been different if the patient was conscious and had a genetic condition associated with an increased risk of rhabdomyolysis. In this case, immediate muscle tissue assessment would have been performed to avoid continued damage to the body.

On the whole, the case describes an incident of rhabdomyolysis caused by an opioid overdose. Rhabdomyolysis is a serious condition involving damage to muscle tissue and leading to the release of cell components into the bloodstream, which is why it is potentially life-threatening. The condition can be caused by genetic factors, including metabolic, mitochondrial, and muscle tissue disorders. Hence, patients who are genetically predisposed to rhabdomyolysis should be assessed for it immediately following a high-risk event.

References

Scalco, R. S., Gardiner, A. R., Pitceathly, R. D., Zanoteli, E., Becker, J., Holton, J. L., Houlden, H., Jungbluth, H., & Quinlivan, R. (2015). Rhabdomyolysis: a genetic perspective. Orphanet Journal of Rare Diseases, 10(1), 51-65.

Stahl, K., Rastelli, E., & Schoser, B. (2020). A systematic review on the definition of rhabdomyolysis. Journal of Neurology, 267(4), 877-882.

Substance Abuse and Mental Health Services Administration. (2018). Opioid overdose prevention toolkit. Web.

Torres, P. A., Helmstetter, J. A., Kaye, A. M., & Kaye, A. D. (2015). Rhabdomyolysis: pathogenesis, diagnosis, and treatment. Ochsner Journal, 15(1), 58-69.

When the course stated, I never knew the difference between bibliographies and annotated bibliographies. My assumption was that writers use the same format while preparing both type of bibliographies. However, from our first lesson, the initial description of annotated bibliography by the instructor showed that it requires a brief description of each reference. The description helps each reader understand the relevance, accuracy, and quality of each reference used to prepare a document. Our weekly lessons and course book highlight the importance of choosing the right reference. By choosing the best references it becomes easy to describe their relevance and importance in the written document. This is the main reason why I cherry pick my reference list even when using different formats to represent my references. Each reader always wonders whether all references listed at the end of a paper were actually used to prepare the document. Annotated bibliography helps since it offers a brief paragraph on the relevance and quality of each reference. However, there are still unclear factors when it comes to annotated bibliographies. How does a writer offer annotation on a mathematical reference?

One of my potential sources for the argument research essay is titled “Lessons from corporate influence in the opioid epidemic”. The journal was authored by Jonathan H. Marks and published in 2020 (Marks, 2020). The journal is better compared to the other available journals as it tries to establish the relationship between pharmaceutical companies and the opioids epidemic. It looks at how corporate marketing of various pharmaceuticals has influenced the opioid pandemic (Marks, 2020). The journal highlights how institutional and societal cultures leads to partnerships with industries through the promotion of products without understanding their impact on society. The journal covers the opioids issues currently affecting society. This includes pain management which eventually leads to opioids abuse. This information is relevant in identifying the cause of the opioids crisis and how it affects society. The information used in the journal comes from medical publication and other reliable sources. I had to read through the journal 3 times before identifying the main issues being addressed in the document. As a result, I gained more insight on the source of the opioids pandemic.

Reference

Marks, J.H. (2020). Lessons from corporate influence in the opioid epidemic: Toward a norm of separation. Journal of Bioethical Inquiry, 17(2), 173-189.

Introduction

Opioid abuse is one of the major burdens of the US healthcare system. Every year, millions of citizens are diagnosed with opioid abuse; the outcomes of it are often fatal. Among other healthcare practitioners, dentists are accountable for prescribing many types of opioid analgesics. Whereas many patients may about their real symptoms to obtain the desired prescription, some physicians do not follow all the necessary precautions to avoid the problem of overprescription. The problem of opioid overuse in the USA has become highly acute, and effective solutions are crucial to mitigate the growing risk. Hence, it is crucial to evaluate the level of prescriptions among dentists and outline the possible ways of reducing them. The present paper argues that dentists need enhanced training on pain management and should implement innovative technologies to manage their patients’ prescriptions to avoid adverse outcomes.

Opioid Prescription in Dentistry

The scope of dentists’ practice involves a variety of skills and operations, including treatment, surgery, and pain relief. The latter is an especially crucial issue since it involves prescribing opioids to patients with the aim of minimizing their pain. Research indicates that many dental specialists fail to adhere to the suggested opioid prescription guidelines (Lutfiyya, Gross, Schvaneveldt, Woo, & Lipsky, 2018). The aspects of dentists’ approaches to the process of narcotic prescription will be discussed in detail below.

In the USA, dentists prescribe analgesic opioids to their patients extensively. As Steinmetz, Zheng, Okunseri, Szabo, and Okunseri (2017) report, the growing number of such prescriptions is becoming a serious public health concern in the country. There are several risks associated with excessive opioid prescriptions in dentistry. First, dental patients tend to have opioid leftovers frequently, which makes them vulnerable to narcotic misuse and overuse (Lutfiyya et al., 2018). Second, there is reported disproportionality in dentists’ prescriptions by age. For instance, more than 30% of all prescriptions are written for adolescents (Lutfiyya et al., 2018). For patients of this age, such practice is particularly dangerous since even one opioid prescription has the potential to raise the “lifetime risk for future opioid abuse” (Lutfiyya et al., 2018, p. 1012).

Reasons for Prescribing Antibiotics

It is vital to note that dentists prescribe opioids for compelling reasons. For example, Baker, Avorn, Levin, and Bateman (2016) report that it is highly common to prescribe opioid analgesics after surgical tooth extraction. This issue can be considered problematic as opioids are not the most effective option for pain reduction. Although there is no sufficient data on nationwide statistics of opioid prescribing upon this procedure, researchers note that there are non-narcotic alternatives that can show similar results in patients, too. For example, Baker et al. (2016) report that the combination of acetaminophen and nonsteroidal medications has the potential to provide effective analgesia for dentists’ post-operative patients. Therefore, although dentists have no legal restrictions to prescribing opioids for patients who have undergone operative treatment, they may use it to their detriment.

Other common reasons to prescribe opioids in dentistry include diagnostic, restorative, preventive, and periodontal procedures, surgical and orthodontic manipulations, root canal treatment, and implant installation (Steinmetz et al., 2017). For example, dentists may prescribe opioids to reduce acute pain and as a follow-up measure after a third moral extraction. It is vital to mention that dentists tend to engage in overprescription due to several reasons, including easy access to opioid substances in rural locations, low cost, and a lack of stigmatization in comparison to illicit drugs (Steinmetz et al., 2017). The outcomes of this challenging issue include chronic pain, opioid abuse, and mental health issues in patients, and will be addressed in the following section of the paper.

Results of Overprescription

One of the primary reasons why overprescription of opioids has become a concern is that if acute pain is not managed properly, it is likely to develop into persistent or even chronic pain in individuals (Moore, 2009). Dana, Azarpazhooh, Laghapour, Suda, and Okunseri (2018) note that even appropriate use of opioid analgesics can cause severe adverse outcomes, such as loss of consciousness and development of infections. For example, prescribing antibiotics to manage the symptoms of the prophylaxis of dental infections can lead to Clostridium difficile infection (Thornhill et al., 2015). In addition, opioid misuse can lead to severe outcomes in pregnant females. For instance, McCarthy, Leamon, Finnegan, and Fassbender (2017) report that drug misuse is associated with an increased risk for comorbidities and mortality, as well as enhanced risk for neonatal abstinence syndrome and fatal withdrawal. Furthermore, excessive prescriptions also serve as an additional financial burden. According to Katz et al. (2013), the cost of treatment of opioid abuse and overdose exceeds tens of millions of dollars yearly.

Studies suggest that even a single case of opioid misuse can lead to severe outcomes in patients. For instance, McCauley et al. (2016) report that the history of previous opioid prescriptions has the potential to cause opioid misuse and abuse in the future. As a result of continuous overprescription, patients may develop chronic substance use disorders and overdose; accidental deaths are among the adverse results of the issue as well. These facts suggest that the procedure of prescribing opioid drugs to dental patients requires significant attention, caution, and precision even if performed once.

The Problem of Opioid Misuse/Abuse and Overprescription

Statistical Data

There is a growing concern among healthcare specialists and researchers about the level of opioid misuse. As mentioned above, while opioids have a high potential to reduce pain rapidly and effectively, they are also likely to be misused or abused, causing addiction. Scholars note that between 5% and 25% of all prescription opioids are not used to satisfy medical needs (Denisco et al., 2011). Over the past few decades, a growing rate of non-medical use of opioids has contributed to both fatal and nonfatal outcomes. The role of dentists in the process of opioid misuse and abuse is critical since these specialists usually prescribe immediate-release (IR) opioids, especially oxycodone and hydrocodone, frequently (Denisco et al., 2011). Notably, dentists are responsible for prescribing almost 15% of IR opioids (Denisco et al., 2011). The current data reveal that these medical professionals are accountable for the largest percent of opioid prescriptions along with family physicians. Thus, it is possible to conclude that dentists contribute to the excessive use of opioids significantly, as abusers commonly use IR opioids in particular.

Recent research studies report a growing number of individuals suffering from a substance use disorder. As of 2015, around 20.8 million Americans were identified as drug abusers (Nack, Haas, & Portnof, 2017). Among them, 2.0 million Americans had a prescription pain reliever disorder, which demonstrated an increase of almost 1.5% between 2013 and 2015. It is crucial to mention that US citizens constitute the largest opioid consumer group in the world. While Americans comprise less than 5% of the world’s population, they are responsible for using up to 80% of opioids in general and almost 100% of hydrocodone, in particular (Nack et al., 2017). The prescription statistics are alarming, as they grew from around 190% in 1997 to more than 585% in 2005 (Nack et al., 2017). In addition, statistical data prove that opioid overuse can often lead to fatal outcomes. Researchers note that these substances count for more fatal cases than heroin and cocaine. For instance, in 2015, around 65% of deaths associated with drug overdose were opioid-related (Nack et al., 2017). In comparison, within the past several years, more people have died of opioid overuse than of car accidents. These data constitute the need to educate dentists on opioid use disorder.

Causes of Overprescription

Several causes may contribute to the incidence of opioid misuse among the population. For instance, some dentists may lack sufficient knowledge of pain varieties or approaches to pain management, resulting in their inability to deny a prescription. Moreover, unfortunately, dental pain is frequently exploited by narcotic-abusing patients (Hupp, 2013). A person may come to the dentist’s office or emergency room complaining about severe pain and requesting immediate help. Many patients simulating pain with the aim of obtaining a prescription may be insistent and convincing, which can potentially lead to decreased alertness in medical professionals (Hupp, 2013). In such cases, it is crucial to remember that most likely, a person truly experiencing pain will agree to pulpotomy or extraction. Meanwhile, there are individuals who do not exhibit real signs of acute ache but agree to no other treatment than an opioid-involving one (Hupp, 2013). Thus, dentists should pay special attention to these patients since they are most likely to be abusers.

The analysis of current literature also reveals the evidence that some physicians abuse their professional competency and prescribe opioids in quantities larger than sufficient. For instance, Chen, Humphreys, Shah, and Lembke (2016) have investigated the distribution of opioids by different healthcare specialists. The analysis was focused on drugs containing such substances as oxycodone, hydrocodone, hydromorphone, levorphanol, oxymorphone, fentanyl, methadone, codeine, meperidine, morphine, and opium (Chen et al., 2016). Scholars concluded that the main cause of opioid overprescription was a small number of “prolific prescribers” responsible for about one-third of opioid prescriptions (Chen et al., 2016, p. 259). The findings of this study suggest that it is crucial to perform in-depth investigations on each dentists’ practices and approaches to pain management.

The data presented above shows that oral health practitioners have to be cautious of patients’ likelihood to be opioid abusers. With the increased opportunities of obtaining illicit drugs on the street, the extent of the problem may be considered close to an epidemic (Solomons & Moipolai, 2014). The responsibilities of dentists, therefore, include not only the treatment of toothache and tooth infections but also observation, identification, and recognition of opioid abuse-related oral health complications.

Racial-Ethnic and Gender Disparities in Opioid Prescription

In investigations of opioid use, researchers mention the issue of unequal prescription and distribution of opioids in addition to the problem of overprescription. As Steinmetz et al. (2017) report, the likelihood of receiving opioid prescriptions is higher for certain vulnerable and ethnic minority populations. Specifically, scholars note that people with low income and no or low level of education receive prescriptions more often than individuals having more economic and social advantages. The same disparity can be traced from the perspective of racial differences. Researchers note that there is a higher mortality rate among African Americans than among Caucasians due to a higher number of prescriptions in the former group (Steinmetz et al., 2017). The results of the study by Singhal, Tien, and Hsia (2016) also demonstrate differences in opioid prescription rates based on ethnicity. Scholars emphasize that non-Hispanic white patients are more likely to receive a prescription for abdominal pain and back pain. However, non-Hispanic Blacks receive more prescriptions for a toothache (Singhal et al., 2016).

The findings presented above reveal that, when considering the methods of eliminating the adverse effect of opioid overuse among Americans, it is crucial to consider ethnic disparities among patients, as they often serve as a basis for the disproportionate prescription of opioids. However, this factor is not the only example of differences emerging during the process of prescribing opioids. LeResche (2011) reports that opioid prescriptions tend to differ by patients’ sex; for example, females are more likely to receive a long-term opioid prescription than males. This fact is potentially associated with a higher rate of lifetime use of opioids by women than by men (Serdarevic, Striley, & Cottler, 2017). The problem of gender and ethnic disparities in opioid prescription deserves thorough analysis since it is likely to aggravate the incidence of deaths due to opioid abuse and overdose in certain population groups.

Recommendations for Avoiding Opioid Misuse and Overprescription

Taking into account all of the problems associated with opioid abuse, misuse, and overdose presented in the previous sections of the paper, it is crucial to develop viable solutions for dentists regarding the elimination of the risks leading to adverse outcomes. One of the most effective solutions is the implementation of an electronic health record (EHR) protocol for patients (Wright, Becker, & Schiff, 2016; Zivin et al., 2018). Specifically, Wright et al. (2016) suggest programming EHRs show the number of drugs prescribed to the patient over the past 30 days before the moment of prescribing opioids. Additionally, scholars offer the implementation of the option of the early refill alert. As a result of such an approach, a practitioner will be able to see if the patient has used up the supply of opioids within the period much shorter than prescribed (Wright et al., 2016). Through this implementation, the task of tracking drug prescriptions can be transformed from a time-consuming procedure to a potentially effective element of the prescribing process.

Another major recommendation to avoid overprescription refers to educational and training endeavors. The Centers for Disease Control (CDC) issued the CDC Guidelines for Prescription Opioids for Chronic Pain in 2016, which is used as a guiding document for many state boards (McEwen & Prakken, 2018). The recommendations features in these guidelines explain when to initiate opioids, how to select the right dose, and when to continue or discontinue opioid use. Additionally, the CDC insists on healthcare practitioners’ regular training and education on pain management (Olsen, 2016). Finally, as mentioned above, each medical professional, including dentists, can take some measures to avoid opioid misuse and overprescription by carefully analyzing each particular patient’s case. It may be crucial for healthcare professionals to offer an alternative treatment or refuse to prescribe opioids significantly reduces the risk of overdose.

Alterations in Dental Treatment if a Patient is on Opioids

Some patients may require changes in dental treatment if they are opioid-dependent and cannot be treated with the help of opioid analgesics. When a person attending a dentist has acute pain, it may be challenging for the specialist to distinguish between real pain and addiction (Nack et al., 2017). Therefore, dental specialists have to create a referral base including pain management professionals, psychiatrists, and addiction specialists. Several reasons for referring a patient to an addiction specialist have been identified. They include positive opioid screens or opioid abuse, excessive alcohol consumption, mental symptoms, concurrent prescription for sedatives and opioids, refusal to try other pain-relieving options, and an opioid use disorder with continuous impairing pain (Becker, Merlin, Manhapra, & Edens, 2016). Addiction specialists can test patients for opioid abuse and share the results with dentists upon request. The most reliable way to assess along-term abuse is using hair samples, while recent use can be detected by a urine test (Nack et al., 2017).

Upon confirming the abusive status of a patient, a dentist should decide on an alternative treatment method. Most frequently, opioid antagonists (naltrexone) or long-lasting opioids (methadone or buprenorphine) are utilized to treat opioid-dependent patients (Nack et al., 2017). The use of long-lasting opioids allows mitigating withdrawal symptoms, and then, the dentist can progressively reduce the dose until the patient stops withdrawing in its absence. Out of the two suggested long-lasting opioids, buprenorphine is more commonly used by US dentists (Nack et al., 2017). Buprenorphine is an “opioid partial agonist” with a “high affinity for the opioid receptor” (Nack et al., 2017, p. 183). The most typical form of buprenorphine prescribed for opioid-dependent patients is Suboxone, a 4:1 combination of buprenorphine and naxolone. Because long-term users can experience withdrawal symptoms upon stopping buprenorphine, it is crucial to consult with the addiction professional before prescribing any painkillers for such patients (Nack et al., 2017).

For most dental and oral surgical operations, specialists recommend nonsteroidal anti-inflammatory drugs (NSAIDs) “with or without concomitant acetaminophen” instead of opioid-based drugs while continuing buprenorphine (Nack et al., 2017, p. 183). For postoperative patients, Suboxone has proved successful as an opioid replacement. For anesthesiology purposes in dentistry, intubated inhalation anesthesia is recommended (Nack et al., 2017). Therefore, there are some effective ways of replacing opioids in the dental treatment of opioid-abusing patients. The dentist’s role in such a case is to identify an abuser timely and address the addiction specialist to create the most suitable treatment plan.

Conclusion

The analysis of the problem of opioid overuse and overprescription in dentistry allows for concluding that it is an acute issue in the US healthcare system. Many patients addressing dentists or emergency care units with toothache pretend that they are in pain to obtain an opioid prescription that will be later used for non-medical purposes. At the same time, many practitioners lack knowledge or attention to such instances, which results in an excessively high rate of opioid use, misuse, abuse, and overuse among US citizens. The problem is aggravated by the fact that doctors tend to prescribe opioids differently to various ethnic groups and genders. The most viable solution in the present situation is to improve the electronic health record system so that it would contain information on opioid prescriptions and would have an option of the early refill alert. Only by combining the efforts of dentists, addiction professionals, and psychiatrists will it become possible to eliminate the epidemic of opioid abuse in the USA.

References

Baker, J. A., Avorn, J., Levin, R., & Bateman, B. T. (2016). Opioid prescribing after surgical extraction of teeth in Medicaid patients, 2000-2010. JAMA, 315(15), 1653-1654.

Becker, W. C., Merlin, J. S., Manhapra, A., & Edens, E. L. (2016). Management of patients with issues related to opioid safety, efficacy and/or misuse: A case series from an integrated, interdisciplinary clinic. Addiction Science & Clinical Practice, 11(3).

Chen, J. H., Humphreys, K., Shah, N. H., & Lembke, A. (2016). Distribution of opioids by different types of Medicare prescribers. JAMA Internal Medicine, 176(2), 259–261.

Dana, R., Azarpazhooh, A., Laghapour, N., Suda, K. J., & Okunseri, C. (2018). Role of dentists in prescribing opioid analgesics and antibiotics. Dental Clinics of North America, 62(2), 279–294.

Denisco, R. C., Kenna, G. A., O’Neil, M. G., Kulich, R. J., Moore, P. A., Kane, W. T., … Katz, N. P. (2011). Prevention of prescription opioid abuse. The Journal of the American Dental Association, 142(7), 800–810.

Hupp, J. R. (2013). Emergency department bane—Dental pain used to obtain narcotics. Journal of Oral and Maxillofacial Surgery, 71(12), 2009–2010.

Katz, N. P., Birnbaum, H, Brennan, M. J., Freedman, J. D., Gilmore, G. P., Jay, D., … White, A. G. (2013). Prescription opioid abuse: Challenges and opportunities for payers. The American Journal of Managed Care, 19(4), 295–302.

LeResche, L. (2011). Defining gender disparities in pain management. Clinical Orthopaedics and Related Research, 469(7), 1871–1877.

Lutfiyya, M. N., Gross, A. J., Schvaneveldt, N., Woo, A., & Lipsky, M. S. (2018). A scoping review exploring the opioid prescribing practices of US dental professionals. The Journal of the American Dental Association, 149(12), 1011-1023.

McCarthy, J. J., Leamon, M. H., Finnegan, L. P., & Fassbender, C. (2017). Opioid dependence and pregnancy: Minimizing stress on the fetal brain. American Journal of Obstetrics and Gynecology, 216(3), 226-231.

McCauley, J. L., Hyer, J. M., Ramakrishnan, V. R., Leite, R., Melvin, C. L., Fillingim, R. B., … Brady, K. T. (2016). Dental opioid prescribing and multiple opioid prescriptions among dental patients. The Journal of the American Dental Association, 147(7), 537-544.

McEwen, S., & Prakken, S. (2018). Reducing the oversupply of prescription opioids. North Carolina Medical Journal, 79(3), 175–180.

Moore, N. D. (2009). In search of an ideal analgesic for common acute pain. Acute Pain, 11(3-4), 129-137.

Nack, B., Haas, S. E., & Portnof, J. (2017). Opioid use disorder in dental patients: The latest on how to identify, treat, refer and apply laws and regulations in your practice. Anesthesia Progress, 64(3), 178-187.

Olsen, Y. (2016). The CDC guideline on opioid prescribing. JAMA, 315(15), 1577-1579.

Serdarevic, M., Striley, C. W., & Cottler, L. B. (2017). Sex differences in prescription opioid use. Current Opinion in Psychiatry, 30(4), 238–246.

Singhal, A., Tien, Y.-Y., & Hsia, R. Y. (2016). Racial-ethnic disparities in opioid prescriptions at emergency department visits for conditions commonly associated with prescription drug abuse. PLOS ONE, 11(8).

Solomons, Y. F., & Moipolai, P. D. (2014). Substance abuse: Case management and dental treatment. South African Dental Journal, 69(7), 298-315.

Steinmetz, C. N., Zheng, C., Okunseri, E., Szabo, A., & Okunseri, C. (2017). Opioid analgesic prescribing practices of dental professionals in the United States. JDR Clinical & Translational Research, 2(3), 241–248.

Thornhill, M. H., Dayer, M. J., Prendergast, B., Baddour, L. M., Jones, S., & Lockhart, P. B. (2015). Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis. Journal of Antimicrobial Chemotherapy, 70(8), 2382-2388.

Wright, A. P., Becker, W. C., & Schiff, G. D. (2016). Strategies for flipping the script on opioid overprescribing. JAMA Internal Medicine, 176(1), 7-8.

Zivin, K., White, J. O., Chao, S., Christensen, A. L., Horner, L., Petersen, D. M., … Jones, C. M. (2018). Implementing electronic health record default settings to reduce opioid overprescribing: A pilot study. Pain Medicine, 20(1), 103-112.

Your Revised Thesis Statement

There is an opioid crisis affecting the healthcare sector with other far-reaching consequences. The situation originated by pharmaceutical organizations believed to be giving more than enough drugs (Marks, 2020). Physicians who accept direct payments or bribes from suppliers and manufacturers for opioid prescriptions are likely to recommend significantly larger medication quantities (Marks, 2020). Medical practitioners and healthcare workers bear the burden of ethics regarding the excessive use of opioids, as observed in the evidence provided, to prove how they have every tool at hand to prevent it.

Your Prewriting

Brainstorm for a list of five reasons your stance is important and valid, and write those five reasons below

• Pharmaceutical companies are providing more drugs than recommended as a deception to influence dozes by medical experts.
• Companies are colluding with healthcare facilities to sell more for some commission and revenues.
• Some medicines work well in large quantities to meet the required standards of treatment.
• Several medical officials invest in companies producing drugs, hence the influence in the large doses.
• Large quantities of opioids are the solution to fighting pain.

Brainstorm for a list of five reasonable opposing arguments others may make against your thesis/stance and write those five opposing arguments below

• Pharmaceutical companies are just doing their normal business without forcing anyone to buy their drugs. The exercise remains a task of pharmacists, who should carry the blame.
• Healthcare institutions should be on the outlook to regulate the dosage and prescriptions given.
• The misuse of drugs is on the rise, and opioids are not the only types on the list.
• The human body is not developing enough immunity to fight diseases, hence the need for more drugs.
• Medicines manufactured in the current days and age are of low quality and can only function when taken in overdose.

Your Introduction Paragraph Draft

The healthcare department has a case to solve at any given time. It could relate to the professionals or the public that they serve. At times, the crisis falls even to the stakeholders operating the medical department. According to King (2018), opioid use and misuse have been on the rise, with medical practitioners in the mess’s limelight. Health associations are worried about the rising crisis that will soon declare the country as abusing drugs. Around 1990 when the concerns were beyond containment levels, medical manufacturers reiterated to the populace that the crisis would as soon as it began. However, the trend has been on the rising curve since then, leaving people with a barrage of questions to solve the riddle (Graeme, 2017). There are reasons justifying the blame on medical experts and stakeholders, while others are mentioning that the increasing cases are beyond the medics. Medical experts should be responsible for the blame regarding the excessive use of opioids, given the evidence provided and their ability to correct the mistakes.

Your Argument Plan

Claim

Medical professionals and stakeholders should bear the direct blame for the misuse of opioids in relieving pain.

Grounds, Warrant, and Backing

“Overdose Data to Action (OD2A) is a 3-year cooperative agreement through which CDC funds health departments in 47 states, Washington DC, two territories, and 16 cities and counties for surveillance and prevention efforts” ( Center for Disease Control and Prevention, n.d). The provision of medical funds for surveillance means there are underhand deals that the government wishes to hijack and stop. According to National Institute on Drug Abuse (n.d), most of these touch on medical experts who understand the problems they should be preventing but fail to do. In other words, it is an act of negligence and disregard to the laws guiding the medical facilities and patients. According to Cobin et al. (2017), there exist various drug agencies to control the use of drugs. These include their sale and manufacture in hospitals and companies, respectively. This means that the agencies as Food and Drug Administration (FDA) and Drug Enforcement Agency (DEA) are not exercising their full authority to ensure the use of drugs reduce.

Counterclaim

Others may claim that the FDA and DEA should provide every stakeholder with the guidelines to follow and prosecute practitioners that do not abide by the law. Since there is no evidence of their efforts, it means the mess is now at the agencies’ and medical practitioners’ discretion. Patients do not face harsh judgment while they are the major people at the center of the argument about the misuse of the drugs.

Rebuttal

It is not clear that the agencies mentioned cannot afford to regulate medicinal misuse. Most companies operate without a trace, leaving little evidence to warrant prosecution. It is also not within their jurisdiction to control what companies manufacture, as that is under the trade department. Additionally, the large numbers of medical practitioners and manufacturers involved within and outside the country are more than the forces established by the regulatory bodies to handle comprehensively. The rising cases of opioid misuse are within the misdoings of countless healthcare organizations, stakeholders, and manufacturers. Evidence point back at their failure to remain ethical in the process, making it tricky to control the use of drugs.

Conclusion

The misuse of drugs and opioid overdose occurs because of inadequate control measures by the regulatory bodies. Medical facilities are also in the conundrum of promoting the mess in drug misuse as they encourage patients to use more than is needed. The government does not provide enough regulation or is sometimes overwhelmed by the cases. Such an incident leaves a gap and leeway for the patients and medical practitioners to use the drugs in ways they find satisfactory to their needs. There should be a plan to reduce the cases to regain the trust of the healthcare sector.

References

Center for Disease Control and Prevention. (n.d). Understanding the epidemic.

Cobin, S., Raeford, B., Derric, V., John, M., & Banu, R. (2017). The US opioid crisis: Crrent federal and state legal issues. Anesthesia and Analgesia, 25(105), 1675–1681.

Graeme, D., W. (2017). The opioid epidemic of America: What you need know about the opiate and opioid crisis… And how we can heal from it. CreateSpace Independent Publishing Platform.

King, S. A. (2018). The opioid epidemic: Who is to blame? Psychiatric Times, 35(6).

Marks, J. H. (2020). Lessons from corporate influence in the opioid epidemic: Toward a norm of separation. Bioethical Inquiry, 17, 173–189.

National Institute on Drug Abuse. (n.d). Opioid overdose crisis.

The opioid crisis endures to be a huge civic health concern in the United States of America as well as globally. The impact of fentanyl on the prevalence of non-fatal overdoses between those who apply narcotics is little understood, despite fast increases in fentanyl-related mortality across the country in recent years. Studies have revealed that syringe services program clients are prone to overdose, which is most likely attached to the exposure of fentanyl compounds. The article aims at explicitly analyzing the different sources of fentanyl compounds in the context of the opioid crisis as well as in the regulatory framework. It further brings into detail the normal routes of exposure of fentanyl compounds in the area of the rising cases of the opioid and regulatory framework.

Sources of Fentanyl compounds in the opioid crisis context

There are several sources of the fentanyl compound concerning opioid crisis and regulatory framework which includes but is not limited to high uptake of naloxone pieces of training, syringe services programs as well as contaminations by the said compound. To start with, high uptake of naloxone training becomes the leading source of the fentanyl compound in the context of the opioid crisis. Naloxone refers to a prescription drug that is capable of stopping the effect of opioids.

Naloxone refers to opioid receptor antagonist, which means that it links to opioid receptors and either reverses or prevents the effects of other opioids from being experienced (Park et.al, 2018). The administration of naloxone rapidly rears the effects of opioid drugs, allowing the patient to resume normal breathing conditions. An injection or a nasal spray can be used to administer the drug. Excessive consumption of naloxone leads to an opioid crisis and thus it should be moderated.

Also, another source of this compound in the opioid crisis context is the syringe services programs. The continued implementation of these programs places the clients at higher risks of overdosage of fentanyl compounds. This is brought by uncontrolled amounts of these drugs with fentanyl compounds in them as the constituent elements there. A national public health emergency involving the misuse of prescription opioid pain medications, as well as heroin and fentanyl, is currently underway in the United States (Park et.al, 2018). Because of this abuse, there has been a surge in insecure injection practices, putting those who inject drugs at danger of overdose deaths as well as the acquisition and transmission of blood-borne infectious illnesses. The program contributes to unsafe injections of fentanyl, with the overdosage leading to the opioid crisis.

Moreover, the over availability of fentanyl compounds in the market has steered opioid overuse. There has been increased supply both locally as well as in the national market of fentanyl and fentanyl-related compounds and drugs. By making these drugs readily available promotes addiction. Fentanyl compounds are highly potent and this drastically increases the risk of overdose. The fentanyl that is illegally used and is most typically related to recent overdoses is manufactured in laboratories (Park et.al, 2018). In addition to being marketed illegally as a powder, it is also dripped into blotter paper, placed in nasal sprays as well as eye droppers, and manufactured into tablets that appear like other treatment opioids. Several drug dealers are mixing fentanyl with other substances, such as cocaine, heroin, as well as methamphetamine, to create a more potent combination.

Lastly, among the sources of the fentanyl compound is contamination. It is done either willingly to enhance the use of substance abuse as a result of the adverse effects these opioids have on one’s health. In the contextual regulatory framework as well as the opioid crisis, the use of drugs that are highly contaminated with fentanyl is a major source of the health crisis. The latter is being blended with other illegal narcotics to improving the effectiveness of the drug. It is being marketed as nasal sprays and powders, and it is progressively being pressed into tablets that are designed to seem like legitimate prescription opioid medications.

In part due to the lack of government oversight and quality control, these counterfeit tablets frequently contain fatal amounts of fentanyl and little or no of the medicine that was promised. High risk exists that illegal drugs have been purposefully laced with fentanyl, which is extremely dangerous (Park et.al, 2018).

Normal routes of exposure of Fentanyl compounds

There are several routes of exposure through which one can get in touch with the fentanyl compounds in this opioid crisis context. These ways include; absorption through inhalation, ingestion which is also referred to as oral exposure, or by skin contact. Further, fentanyl has a high possibility of being administered intramuscularly, as a skin patch, a practice commonly known as transdermal exposure, and lastly, it can be administered intravenously.

Inhalation of fentanyl causes rapid absorption. It often happens as one inhales the aerosols which are contaminated with fentanyl compounds as well as inhaling the powders as fentanyl; can be in form of a powder. This causes delayed reduces respiratory function as well as respiratory arrest. By inhaling the airborne powder is most likely associated with harmful effects such as lethargy, disorientation, drowsiness as well as nervous system depression (Moss et.al, 2018). Another route of exposure is ingestion of oral exposure. It occurs as a result of poisoning or contamination by fentanyl. It can be used to contaminate the water which is used to quench thirst or one can get exposed to fentanyl when it is used to contaminate foods. This method of exposure occurs by mouth through swallowing.

Moreover, it can be exposed via skin contact. This is the route of exposure whereby there is direct contact of fentanyl compounds with human skin. This normal route of exposure can be curbed by the use of personal protective equipment and clothing. Skin contact route of exposure cannot have harmful effects unless there is prolonged exposure of very large amounts of the compound (Moss et.al, 2018). However, skin contact exposure to fentanyl compounds can be very toxic. If any apparent contamination is removed as soon as possible, it is unlikely that brief skin contact with illicit fentanyl will result in harmful effects.

Apart from the major routes of exposure known, fentanyl can also be administered intravenously. This occurs when fentanyl compounds are injected directly into the veins. It occurs for concentrated medications that are either diluted or undiluted by using syringes via needleless ports on an intravenous line that is in existence (Moss et.al, 2018). On the other hand, intramuscular injection is a procedure that is used to administer a drug deep into the muscles of the patient. This allows for rapid absorption of the medicine into the bloodstream. This can lead to exposure to fentanyl compounds in the bloodstream and continuous exposure translates to an opioid crisis.

Also, there is a certain brand of fentanyl which is a patch prescribed by the health care providers to be applied to the skin, a practice known as transdermal administration. These patches may lead to life-threatening breathing complications. Given this substantial danger, fentanyl patches should only be applied to treat persons who are lenient (have become acclimated to the effects of the medicine) to opioid medications and have been taking this type of medication for at least one week before using them (Moss et.al, 2018).

References

Park, J. N., Weir, B. W., Allen, S. T., Chaulk, P., & Sherman, S. G. (2018). Fentanyl-contaminated drugs and non-fatal overdose among people who inject drugs in Baltimore, MD. Harm reduction journal, 15(1), 1-8. Web.

Moss, M. J., Warrick, B. J., Nelson, L. S., McKay, C. A., Dubé, P. A., Gosselin, S.,… & Stolbach, A. I. (2018). ACMT and AACT position statement: preventing occupational fentanyl and fentanyl analog exposure to emergency responders. Clinical Toxicology, 56(4), 297-300. Web.

Opioids are defined as a class of drugs naturally found in the opium poppy plant and are essential in ensuring that the brain produces a broader range of effects. Medically, they are primarily used to relieve pain, suppress diarrhea, reverse the overdose of opioids, and mitigate cough. In some scenarios, they are used as replacement therapy for opioid use disorder. However, this medication has several side effects such as nausea, sedation, itchiness, and long-term use can cause unpleasant withdrawal symptoms. Euphoria also plays a vital role in attracting frequent and recreational use, which eventually leads to addiction. In Ontario, Canada, the opioid crisis is complicated health and the social issue often associated with devastating effects for families, individuals, and communities.

Opioids are among the globe’s oldest known drugs in the modern world. The earliest traces of these drugs were the paper somniferous discovered around 5700 to 5500 BC during the Neolithic period. Its seeds have also been discovered at the Cueva De Los Murcielagos in the Peninsula of Iberian and La Marmotta in the Italian Peninsula. Nevertheless, opium was also shared and well known to the Greeks as Hippocrates, and his students valued it because of its sleep induction characteristics and pain treatment (Fischer et al., 2019). However, during the Islamic Golden Age period, Avicenna was totally against opium not unless it was the last option or resort.

In Ontario, the opioid crisis has been an intricate problem that impacts individuals and the entire community. For example, in three years between 2016 and 2019, approximately 12800 Canadian citizens died because of an overdose of opioids (“Opioid- and stimulant-related harms,” 2021). Typically, this crisis is growing and developing in Canada, especially in Ontario, because it is driven by the illegal and prescription use of this form of drug. Mostly, analogs and fentanyl are responsible for accelerating the rise of opioid-related deaths in Ontario (Irvine et al., 2018). In addition, there were 16 opioid-related hospitalization complications a day and 2900 deaths in the calendar year 2016 (Irvine et al., 2018). Thus, the crisis has significantly contributed to and impacted the lives of Ontario residents and Canadian citizens.

Fentanyl and Carfentanil are regarded as the most dangerous types of opioids, and they have been found on the streets of Ontario. Any form of drug that a qualified and certified medical practitioner does not prescribe could contain a form of fentanyl and Carfentanil (Irvine et al., 2018). Legally these two types of opioids can be used to treat and manage severe pain, while their illegal use is that they might be pressed into more tiny pills and then later sold as fake opioids. As a result, they might lead to overdose and eventually death.

The opioid crisis primarily affects every region and province in Canada, but Ontario and the western provinces of British Columbia are the most affected regions. This is not a challenge that only affects individuals illegally using street drugs. Still, it is a national health concern that affects all individuals across Canada, all age groups, and all social-economic groups (Piske et al., 2020). It is also evident that in Ontario, since 1999, the prescription rates of opioid drugs have increased as it is the fourth most used drug after tobacco, alcohol, and Cannabis sativa, making it the most misused form of drug when comparing it to heroin and cocaine.

There are a variety of routes that have paved the way for the diversion of nonmedical use, which include prescription fraud and forgery, the street drug markets, and also internet purchases that have made it hard to determine the exact proportion that has been diverted or converted. According to Piske et al. (2020), the most common origin of these drugs without a prescription was a family member; however, no significant measures of the prevalence of illegal consumption of opium were detected. Thus, despite opioid overdose and use disorder being a significant challenge, social determinants can play a significant role in preventing and treating opioid use disorder.

Nonetheless, opioid use disorder (OUD) can be evaluated by examining the number of individuals seeking treatment for their levels of opioid dependence. In Ontario, the number of people enrolled in opioid agonist treatment (OAT) has significantly increased from 6000 to above 50000 (Morin et al., 2017). This implies that the province is implementing appropriate and effective policies to mitigate and control the opioid crisis. However, the opioid epidemic or crisis is quite complex as close to 50% of the individuals with OUD tend to have also mental health disorders. An illustration of this is that approximately 87% of individuals with OUD in Ontario also tend to have mental health disorders. In addition, this form of the disorder is common among individuals ranging between 15 to 34 years old (Morin et al., 2017). Thus, more effective treatment strategies should be implemented to help the affected individuals.

In Ontario, there are also cases of substance dependence and stigmatization. Canada generally lacks a consensus on this issue and appropriate and practical solutions, which is a critical barrier to addressing the opioid crisis in Ontario. An example of this is how the perception of addressing and finding practical solutions toward curbing the opioid crisis is incompatible (Fischer et al., 2019). There are also several existing discrepancies between the policy ideas and the research. Therefore, in conjunction with the national government, the Ontario healthcare stakeholders have advocated for various techniques and strategies to mitigate the opioid crisis.

The government has initiated drug prescription and monitoring programs. It has advocated for using a prescription drug monitoring program (PDMP) to identify patients misusing the prescription of opioids or any other drugs. This form of technology alerts and makes one aware of the prescription information and interventions that could be lifesaving. In addition, the national government, in collaboration with the Ontario province, patient education has improved the storage and disposal of these drugs (Fischer et al., 2019). Quality improvement programs have also been initiated and implemented. They have played a vital role in increasing the recommended prescription practices that are crucial to Canadian residents.

Nevertheless, awareness has also been created, especially on the costs associated with overdose of opioids, families and the patients, and most importantly, the risks concerning the prescription. Policymakers and individuals also play a crucial role in resisting and advocating for change regarding the opioid crisis (Fischer et al., 2019). For instance, in November 2018, a multi-year campaign was initiated to increase awareness of opioids. This was followed by the Good Samaritan Drug Overdose Act with a focus to help individuals facing stigma (“Federal actions,” 2021). Thus, the main beneficiaries of curbing the opioid crisis are Ontario residents and general Canadian citizens.

In conclusion, it is clear that despite opioid being essential in relieving pain, it is also associated with several shortcomings and has posed serious health and social problem in Ontario. The drug is often linked with nausea, vomiting, diarrhea, sedation, dizziness, constipation, and even in some scenarios respiratory depression. In addition, Ontario has ensured that individuals affected by matters surrounding opioids have been given full support by adding more front-line workers and ensuring harm reduction. They have achieved this by expanding the naloxone supply and, most importantly, creating more rapid access to addiction clinics with a 10-year funding agreement with the federal government.

References

Federal actions on opioids to date. (2021).Government of Canada. Web.

Fischer, B., Pang, M., & Tyndall, M. (2019). The opioid death crisis in Canada: Crucial lessons for public health. The Lancet Public Health, 4(2), e81-e82. Web.

Irvine, M. A., Buxton, J. A., Otterstatter, M., Balshaw, R., Gustafson, R., Tyndall, M., Kendall, P., Kerr, T., Gilbert, M., & Coombs, D. (2018). A modeling study is the distribution of take-home opioid antagonist kits during a synthetic opioid epidemic in British Columbia, Canada. The Lancet Public Health, 3(5), e218-e225. Web.

Morin, K. A., Eibl, J. K., Franklyn, A. M., & Marsh, D. C. (2017). The opioid crisis: past, present and future policy climate in Ontario, Canada. Substance abuse treatment, prevention, and policy, 12(1), 1-7. Web.

Opioid- and stimulant-related harms in Canada. (2021). Government of Canada. Web.

Piske, M., Zhou, H., Min, J. E., Hongdilokkul, N., Pearce, L. A., Homayra, F., Socias, E., McGowan, G., & Nosyk, B. (2020). The cascade of care for opioid use disorder: A retrospective study in British Columbia, Canada. Addiction, 115(8), 1482-1493. Web.

Introduction

Nurses have been the key advocates for addressing patients’ needs and rights. These healthcare practitioners are aware of patients’ needs and understand the peculiarities of the system with its challenges and opportunities for meeting these needs, which makes nurses perfect advocates (Milstead & Short, 2017). One of the areas nurses can make a difference is the use of opioids. It has been estimated that one in four postoperative patients use opioids, but this alarming rate is often characterized by the overuse of drugs (Hilliard et al., 2018). In many cases, the reasons for prescription are not properly justified, and pain management could be realized with the help of other measures, including patient education.

Healthcare practitioners can and should inform patients about the adverse effects of opioid use and appropriate ways to manage pain. At the same time, medical staff may lack the necessary skills to provide the necessary information within the limited time they have to provide care to a particular patient. This paper includes a brief analysis of a bill that was introduced in 2021 and aimed at providing funds to states where the corresponding incentives are being implemented (see Table 1).

Table 1:Opioid Patients’ Right to Know Act Of 2021

Legislation Testimony/Advocacy Statement

The bill under consideration should be enacted as it can have a positive influence on the situation related to opioid use. Healthcare professionals tend to choose opioids as they have proved to be effective in managing acute pain, and such prescriptions have become a common practice (Hilliard et al., 2018). Hilliard et al. (2018) report that diverse factors are associated with opioid drug use, including but not confined to age, depression, tobacco use, pain severity, low life satisfaction, and comorbidities. These factors should be identified, and the corresponding alternative has to be offered to the patients who are often unaware of the detrimental effects of opioids and available alternatives. Those who prescribe medication need evidence-based data to inform patients and persuade them to employ non-opioid treatment methods of pain management.

However, the medical staff seems to be ill-prepared to provide this kind of care due to the lack of knowledge and skills necessary for catering to patients’ needs within the context of time and resource scarcity. Physicians and nurses have only several minutes per day to communicate with the patient, and during this time, patients receive information regarding their health status, progress, treatment, as well as many other aspects. It is important to provide training to healthcare professionals so that they could improve the quality of care and ensure positive patient outcomes (Yajnik et al., 2019). Nurses can play a central role in this process as these practitioners are in the closest contact with patients and their caregivers.

Moreover, nurses should take an active part in the implementation of the corresponding legislation. By initiating and participating in diverse discourses, nurses should advocate for addressing patients’ needs and the improvement of quality of the provided care, which leads to positive shifts and progress (Taylor et al., 2017). Nurses can discuss the legislation and address administrators, policymakers, nursing organizations to draw stakeholders’ attention to the bill and similar incentives.

Addressing Opponents’ Arguments

The opponents of the bill are likely to oppose the allocation of funds to educate medical staff, arguing that the money could be used in a more effective way. Those who do not support the bill can state that physicians can be simply mandated to prescribe non-opioid medication or develop treatment plans using non-opioid alternatives to manage pain. However, this approach is associated with various challenges, including economic, medical, and ethical. First, some note that opioids should be simply banned with only a limited number of exceptions that are clearly identified. Nevertheless, one of the major ethical values medical personnel follows is beneficence, so they cannot let patients suffer if there is an effective way to address the problem. No alternative to opioids exists in many instances, so the ban can deprive patients of the only opportunity to soothe pain and maintain an appropriate quality of life (Hilliard et al., 2018). Hence, pain management requires the use of strong opioid drugs.

The opponents of the bill may state that if the ban is impossible, it is necessary to develop clear guidelines regarding the exact use of medication in different cases. However, due to the uniqueness of every patient’s condition, these guidelines cannot be strict enough, so healthcare professionals will still decide in each case based on a range of factors (Yajnik et al., 2019). Moreover, patients report their perceived pain, which makes a choice even harder. As mentioned above, healthcare practitioners are short of time and need to make decisions quickly and have only several minutes to communicate with patients (Hilliard et al., 2018). The medical staff needs the training to address this issue effectively as they need evidence to make choices and skills to persuade patients using the most effective and ethical techniques.

Finally, training is an effective type of quality management as it leads to the improvement of the provided services and the entire healthcare system. Yajnik et al. (2019) state that medical personnel education regarding opioids and alternatives leads to the reduction in this medication use, which is a positive effect. The reduction of opioid addiction is one of the health goals of the U. S. government, so the type of investment offered by the bill sponsor is cost-effective and potentially beneficial in terms of public health. Instead of addressing issues associated with addiction, patients may receive care void of the utilization of such drugs. However, the continuous learning of medical staff is the necessary background for the attainment of this objective. Healthcare professionals will have the necessary skills and knowledge and will be motivated to use them when choosing the most appropriate treatment for each patient.

Conclusion

In conclusion, the bill under the title “Opioid Patients’ Right to Know Act of 2021” should be enacted as it can contribute to the further development of the American healthcare system. The bill ensures the provision of funds that are needed for the development of medical staff, making healthcare professionals prepared to improve pain management. Practitioners need the training to choose the most effective alternative to opioid drug use and persuade patients to adhere to the developed treatment plan. Although the bill is associated with the investment of a substantial amount of funds, it may face certain opposition. Nevertheless, benefits are evident, which raises the chance of the legislation to be enacted. At that, nurses should participate in this process actively by articulating patients’ needs and advocating for them. Nurse professionals have to initiate a wide-ranging discussion of the bill and its potential impact. This discussion should involve such stakeholders as patients, nurses, other medical personnel, hospital administration, nursing associations, and organizations, as well as local, state, and federal policymakers. The involvement of these groups will lead to the development of effective programs that will be supported by federal funds.

References

Hilliard, P. E., Waljee, J., Moser, S., Metz, L., Mathis, M., Goesling, J., Cron, D., Clauw, D. J., Englesbe, M., Abecasis, G., & Brummett, C. M. (2018). Prevalence of preoperative opioid use and characteristics associated with opioid use among patients presenting for surgery.JAMA Surgery, 153(10), 929-937. Web.

H.R.1185 – Opioid Patients’ Right to Know Act of 2021. Congress.gov. Web.

Milstead, J. A., & Short, N. M. (2017). Informing public policy: An important role for registered nurses. In J. A. Milstead & N. M. Short (Eds.), Health policy and politics: A nurse’s guide (pp. 1-16). Jones & Bartlett Learning.

Taylor, D., Olshansky, E. F., Woods, N. F., Johnson-Mallard, V., Safriet, B. J., & Hagan, T. (2017). Corrigendum to position statement: Political interference in sexual and reproductive health research and health professional education [Nursing Outlook 65/2 (2017) 242–245]. Nursing Outlook, 65(3), 346-350. Web.

Yajnik, M., Hill, J. N., Hunter, O. O., Howard, S. K., Kim, T. E., Harrison, T. K., & Mariano, E. R. (2019). Patient education and engagement in postoperative pain management decreases opioid use following knee replacement surgery. Patient Education and Counseling, 102(2), 383-387. Web.