Experts urge caution, increased education about opioid use for people with heart disease

More than 67,000 people died due to drug overdoses in the U.S. in 2018, and two-thirds of those deaths involved opioids. In the 12-month period from December 2019 to December 2020, there was a 30% increase in drug overdose deaths compared to the previous 12-month period, according to a recent, provisional data analysis from the U.S. Centers for Disease Control and Prevention. The advisory notes several specific strategies for addressing the issue: improve education and training for the public and health care professionals on how to safely manage pain and opioid overdose; and support treatment for opioid use disorder, including creating and developing partnerships with federal, state, local and employer-based programs. Through strong, collaborative partnerships, healthier communities with more equitable access to care can help to reverse the rate of opioid overdoses and deaths in the U.S.

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

The AHA partnered with a team of leading health authorities -- physicians, scientists and a pharmacist with expertise and knowledge in the field of medicine, pharmacotherapy, research and federal regulations -- to develop the presidential advisory. It highlights recommendations, algorithms and guidance for health care professionals and researchers who specialize in heart and brain health. The volunteer writing group used data and information from more than 90 evidence-based epidemiology studies, reviews, consensus statements and guidelines already published.

"Health care professionals who manage pain in the setting of cardiovascular disease and stroke should be encouraged to receive training in management of pain using non-opioid strategies and on screening for opioid use disorder," said Chow. "Lay responders should also be encouraged to receive formal CPR training with specific instructions on naloxone administration because opioid overdose often occurs in public, and CPR is more likely to be given by bystanders."

Key points detailed in the advisory include:

• CPR guidelines and algorithms are reviewed for both health care professionals and lay rescuers for when a person has a suspected opioid overdose. CPR training for lay people should emphasize calling 911 and initiating CPR before administering naloxone because it may be hard for a lay rescuer to identify the cause of the cardiac arrest, and naloxone will only be effective if opioid overdose is the cause of the cardiac arrest. (Naloxone is an emergency medication that can rapidly and effectively be lifesaving in the case of an opioid or other illicit drug overdose.)

• For people with cardiovascular disease and muscle or joint pain, acetaminophen, aspirin and non-acetylated salicylates should be considered first for pain management as alternatives to opioids.
• Morphine is used to reduce pain for some coronary patients, yet the medication may reduce the therapeutic effectiveness of P2Y12-receptor antagonists (antiplatelet/clot-preventing medications).
• Parenteral antiplatelet agents (medications given intravenously) may be considered for acute coronary syndrome treatment when administered with morphine in the hospital setting.
• An expansion of free, syringe exchange programs should be considered to reduce the risk of infective endocarditis, a serious infection of the heart lining, which can occur when needles are shared for intravenous drug use.
• A coordinated approach to opioid management should occur among federal, state and local health and law enforcement agencies, as well as in the workplace setting through organizational initiatives.

The American Heart Association is committed to advancing the science on opioid use and its effects on patients with cardiovascular disease through evidence-based research; improving education and training for the public and health care professionals on how to safely manage pain or opioid overdose and support treatment for opioid use disorder; and creating and developing partnerships with federal, state, local and employer-based programs.

"This advisory includes both immediate and long-term strategies to help mitigate the devastating intersection of opioid abuse and cardiovascular disease," said Ivor J. Benjamin, M.D., FAHA, former president of the American Heart Association (2017-2018), and director of the cardiovascular center, co-director of the NIH T32 Postdoctoral Fellowship in Cardiovascular Sciences and professor of medicine at the Medical College of Wisconsin in Milwaukee. "Together with our partners throughout public health, policy and government infrastructures, we can help support health care professionals and people in our communities more effectively avoid the preventable deaths caused by opioid use disorder and opioid overdose."

This presidential advisory was prepared by the volunteer writing group on behalf of the American Heart Association.

Co-authors are Comilla Sasson, M.D., Ph.D., FAHA, vice-chair of the writing committee, vice president for science & innovation for emergency cardiovascular care at the American Heart Association; Ivor J. Benjamin, M.D., FAHA, former president of the American Heart Association, and director of the cardiovascular center at the Medical College of Wisconsin; Robert M. Califf, M.D., head of clinical policy and strategy at Verily Life Sciences and Google Health, a former commissioner of the U.S. Food and Drug Administration, former vice chancellor for health data science at Duke University School of Medicine and the founding director of the Duke Clinical Research Institute; Wilson Compton, M.D., M.P.E., deputy director of the National Institute on Drug Abuse (NIDA) of the National Institutes of Health; Elizabeth Oliva, Ph.D., investigator at the VA Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Health Care System and a senior evaluator for the VA Program Evaluation and Resource Center; Chester Robson, D.O., M.H.C.D.S., medical director of clinical programs and quality for Walgreens Corporation; and Eduardo J. Sanchez, M.D., M.P.H., FAHA, FAAFP, the American Heart Association's chief medical officer for prevention.