Opioid misuse (e.g., prescription opioids, heroin) in the United States has tripled over the last two decades,1 causing significant morbidity that led to the Federal government's declaration of the opioid crisis as a public health emergency in 2017.2 Increases in opioid-related hospitalizations, treatment admissions, and overdose deaths have been well-documented by researchers.3,4 However, a potential consequence of opioid misuse that is sometimes overlooked is hearing loss.5
The first documented case of opioid-induced hearing loss dates back to the 1970s,6 but we still know very little about this condition. What we do know is that hearing loss sometimes occurs when opioids are misused. While the prevalence of opioid-induced hearing loss remains unclear, it is reasonable to assume that this type of hearing loss has increased significantly since the opioid crisis began over 20 years ago. With such drastic increases in opioid misuse, audiologists are more likely to encounter patients with opioid-induced hearing loss than in previous decades.
CONSIDERATIONS FOR AUDIOLOGISTS
Opioid misuse can have important clinical implications for audiologists. First, it is worth noting that older adults, manual labor workers, and military veterans, who comprise a sizable proportion of patients for audiologists, have elevated rates of opioid misuse.7-9 Another consideration for audiologists is the possibility that patients who misuse opioids may experience cognitive dysfunction.10 This is relevant because it may negatively impact speech recognition/processing, which means patients who suffer from even mild cognitive dysfunction due to opioid misuse may have poorer hearing aid outcomes.11 Additionally, the successful treatment of opioid-induced hearing loss likely requires abstinence from opioids, which means synchronizing care between audiologists and behavioral health care providers will become increasingly important.5
DISCUSSING OPIOID MISUSE WITH PATIENTS
These considerations highlight the importance of accurately diagnosing opioid-induced hearing loss. Audiologists are encouraged to screen for opioid misuse in all cases of sudden sensorineural or unexplained hearing loss. Since hearing loss is rare when opioids are taken as prescribed,12 questions should primarily focus on nonmedical use (e.g., overuse, improper route of administration).
The stigma around opioid misuse can make it an uncomfortable topic of discussion among patients and providers. Research has shown a long history of providers exhibiting negative attitudes toward patients who misuse opioids, often judging them and even refusing them care.13 With this in mind, clinicians must approach opioid-related discussions in a manner that does not offend or traumatize. While there are best practice protocols for opioid misuse screening in primary care,14 little guidance exists for audiologists. The following recommendations are meant to serve as a guide for providers in audiology settings. These suggestions are based on the National Institute on Drug Abuse's (NIDA) best practices for drug use screening,15 but are tailored specifically for clinical audiologists.
Prior to screening, clinicians should note several logistical considerations. First, relationships should be established with external providers who will accept referrals for additional assessment and/or drug treatment in the case of a positive screen, keeping in mind that a positive screen does not equate to an opioid use disorder. It is recommended to use eighth grade or lower reading level to ensure comprehension.16 Additionally, person-first language (e.g., person with an opioid use disorder, harmful use, non-medical use) should be used instead of outdated terms that perpetuate stigma (e.g., addict, alcoholic, junkie, abuse/abuser).17-18 Audiologists should also be prepared to seek immediate medical assistance should a crisis occur during screening.
OPIOID MISUSE SCREENING SUGGESTIONS
Screening can be conducted as an interview, where questions are read aloud using a non-judgmental, non-confrontational style. These questions can also be provided in writing via a questionnaire. Ideally, the audiologist should already be familiar with the patient and have established a rapport before the screening. Here's the suggested script for introducing the screening process:
“If it's okay with you, I'd like to ask a few more questions to help me better understand the reason for your hearing loss and how to manage it. These questions focus on your experience with alcohol, cigarettes, and other drugs. It would be helpful to learn more about the prescription drugs you have taken (like pain medications), as well as any recreational drugs you have used.”
Asking about cigarettes and alcohol use has become a common practice in health care settings and can provide a comfortable entry point to discuss opioids. If the patient declines the screening, the decision must be respected. However, provide the patient information about the impact of opioid misuse on hearing and offer an opportunity to complete the screen at a follow-up visit.
Once the above script is read aloud and the patient expresses willingness to proceed, the provider could administer the NIDA Quick Screen and/or NIDA-Modified Assist, which are validated instruments designed to assist providers in screening for substance use.19 The Quick Screen should be administered first to ask the patient about the use of illegal or prescription drugs for nonmedical reasons within the past year. If the patient answers “No” on the use of these substances, then the screener is complete, and opioid-induced hearing loss can be ruled out. However, if the patient answers “Yes,” the provider should proceed to the Modified Assist for a more in-depth screen of misuse of prescription opioids or heroin.
If the patient screens positive, the provider should attempt to determine: (1) whether the hearing loss occurred suddenly or immediately after an episode of opioid misuse, (2) the type of opioid misused (noting that methadone, heroin, hydrocodone, morphine, and oxycodone formulations with acetaminophen appear to confer highest hearing loss risk), (3) whether the route of administration was parenteral, (4) the opioid overdose history (noting that overdose can increase risk of hearing loss), (5) whether the patient has used/misused opioid agonist medications to treat opioid use disorder (noting that methadone appears to confer the highest hearing loss risk). This information can aid in determining whether the hearing loss is in fact opioid-induced.
Audiologists are increasingly likely to have patients who misuse opioids or have opioid-induced hearing loss. In cases of sudden sensorineural or unexplained hearing loss, patients should be screened for opioid misuse to determine whether such hearing loss is opioid-induced. The discussed screening suggestions, though not exhaustive, serve as a primer for hearing health care providers. They are meant to be applied broadly and do not address the unique considerations that must be taken into account when screening special populations, such as adolescents or pregnant women. This article should serve as a starting point for discussing how opioid misuse can impact the practice of audiology and provide some initial guidance on how to screen for opioid misuse in audiology settings.