with patients the need for securely storing their opioid medications to prevent misuse by others and possible accidental exposure, especially to children and pets. When opioid treatment is discontinued, advise patients to return unused opioid medications to drug take-back programs sponsored by pharmacies, the DEA, or other local agencies. If these programs are unavailable, counsel patients to dispose of their medicines in the household trash by following these steps: 1. Remove drugs from their original containers and mix them with something undesirable, such as used coffee grounds, dirt, or cat litter. This makes the medicine less appealing to children and pets and unrecognizable to someone who might intentionally go through the trash looking for drugs. 2. Put the mixture in something that can be closed (e.g., a resealable plastic bag, empty can, or another container) to prevent the drug from leaking. 3. Throw the container in the garbage. 4. Delete personal information on empty prescription medication bottles or packaging to protect identity and privacy. Throw the packaging away. 5. Do not flush opioids down the toilet or drain, as this can contaminate the water supply. (Pino & Wakeman, 2022)
consider reassessment. Functional goals and objective evidence of achievement include: ● Participate in physical therapy sessions: Documentation of progress from physical therapist. ● Sleeping in bed instead of chair: Reported by a caregiver, family member. ● Participation in a pain support group: Letter from the group leader. ● Ability to walk around the block: Self-report, pedometer, caregiver, friend . ● Return to work: Pay stubs, a letter from the employer. (HHS, 2019b) Clinicians must be vigilant for aberrant behaviors indicating a patient may be at risk for misuse or abuse of opioids that could result in addiction and substance abuse disorder. A review of PDMP before prescribing or renewing may indicate if the patient is seeing other providers unbeknownst to the primary prescriber. Discuss any unexpected results thoughtfully, as errors in data have been known to occur. Urine drug screening may determine if the patient has ingested other medications or illicit substances beyond the agreed-to treatment plan. Urine screening tests may produce false positives. A qualitative test will confirm any positive result from a urine screening test. Review
MANAGING OPIOID-INDUCED ADVERSE EFFECTS
determining the appropriateness of opioid therapy (FDA, 2022a). The FDA issues a black box warning (BBW) for all prescription opioid pain and cough medications and all prescription benzodiazepines regarding the risk for the CNS depression and serious adverse effects, including respiratory depression and death. The BBW was issued after several studies showed an increasing trend in concomitant dispensing of opioid analgesics and benzodiazepines and an increasing frequency of combined benzodiazepine and prescription opioid misuse, abuse, and overdose as measured by national emergency department visit and overdose death rates from prescribed or greater- than-prescribed doses (FDA, 2021). In addition, other CNS depressants (e.g., barbiturates, antipsychotics, and neuroleptic drugs; antiepileptic and antiparkinsonian drugs; anesthetics; autonomic nervous system drugs; and muscle relaxants) contributed to deaths where opioids were also implicated (SureScripts, 2022b). Tori et al. (2020) found that alcohol and benzodiazepine coinvolvement in opioid-involved overdose deaths was common, varied by opioid subtype, and was associated with state-level binge drinking and benzodiazepine prescribing rates. The FDA states that clinicians should limit prescribing opioid pain medicines with benzodiazepines or other CNS depressants only to patients with inadequate alternative treatment options. Avoid prescribing opioid-containing cough medicines to patients taking benzodiazepines or other CNS depressants, including alcohol. When prescribing medications, limit dosages and the duration of each drug to the least possible while achieving the desired clinical effect. Counseling patients regarding possible adverse severe reactions is critical (FDA, 2021). The FDA clarified this warning for patients taking opioid- addiction medications. Specifically, the FDA advised that the opioid-addiction medications buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the CNS. Although the combined use of these drugs increases the risk of severe side effects, the harm caused by untreated opioid addiction can outweigh these risks. These medications are often used with counseling and behavioral therapies for
An essential component of any chronic opioid therapy follow-up evaluation is assessment for opioid-related adverse effects. Tolerance to acute opioid-induced side effects (e.g., sedation, nausea/vomiting, itching) will develop; however, other adverse effects may continue to be an issue. Additionally, clinicians must be aware of long-term side effects. Opioid-induced constipation is a risk throughout chronic opioid therapy. Therefore, prescribing scheduled use of stool softeners (e.g., docusate) and stimulants for those receiving chronic opioids is warranted. In addition, instruct patients to contact their prescriber if they do not have a bowel movement at least every 2 to 3 days to avoid developing impaction. In some cases, a prescription medication for opioid-induced constipation may be necessary. Patients do not develop tolerance to the opioids’ respiratory depressive effects, even with chronic therapy. Additionally, this risk increases if other CNS depressant agents (prescribed or illicit) or alcohol are concurrent. Consider prescribing naloxone (Narcan), an opioid antagonist, for any patient at risk of opioid-induced respiratory depression. When administered to a patient experiencing an opioid overdose and opioid-induced respiratory depression, naloxone can rapidly reverse all signs and symptoms of opioid intoxication. Many states have passed laws expanding access to naloxone, allowing pharmacists to dispense or distribute naloxone without a prescription under certain circumstances. As part of the FDA’s action plan regarding the safety of opioid analgesics, it has released several safety-related product labeling updates. In addition, the FDA (2018) updated warnings across the entire class of opioids regarding drug interactions, adrenal issues, and alterations in sex hormone levels. Specifically, the FDA warns that opioids may interact with other medications that increase serotonin levels (e.g., certain antidepressants and migraine medications), which may lead to serotonin syndrome. In addition, opioids are rarely associated with adrenal insufficiency, and long-term use of opioids decreases sex hormone levels. Consider these potential drug interactions and adverse effects and discuss them with patients when
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