patients undergoing MAT, and patients can be treated with them indefinitely. Careful patient monitoring is necessary when prescribing benzodiazepines or other CNS-depressant Tapering of chronic opioid therapy (CDC, 2022A) Sometimes, clinicians must decide whether to decrease or discontinue chronic opioid therapy. Many factors may contribute to this decision: patient request; lack of response; signs of substance abuse disorder, overdose, or other serious adverse events; or early signs of overdose risk. Therefore, any tapering schedule must be patient-specific to minimize withdrawal symptoms while maintaining adequate pain management. A general recommendation is to begin with a 10% decrease of the initial dose per week. Some patients who have taken opioids for a long time may require slower tapers (e.g., 10% per month). Adjust the rate and duration of the taper based on the patient’s response. It is advisable to slow or pause a taper to manage withdrawal symptoms rather than reversing the taper. It is essential to discuss the risk of overdose if a patient quickly returns to a prescribed higher dose. Consider prescribing naloxone to reverse possible overdose symptoms. After achieving the smallest available dose, the interval between opioid doses increases, and opioids stop when taken less than once a day. Naloxone for emergent opioid overdose On average, every eight minutes, an individual dies from an opioid overdose (Skolnick, 2018). Individuals at higher risk for acute overdose include those who use prescription opioids, benzodiazepines, and alcohol, as well as individuals with substance or mental health use disorders. These factors affect the entire family since these individuals may obtain opioids from family members. Children are at risk when ingesting opioids in the home. Individuals who have lower tolerance due to incarceration, detoxification, or other controlled settings are also at higher risk for acute opioid overdose. Physiological damage can occur after 4 minutes, and death occurs in 4 to 6 minutes. Signs and symptoms of acute opioid overdose include: ● Unusual sleepiness or unresponsiveness. ● Decreased or absent breathing. ● Slow heartbeat or low blood pressure. ● Skin feels cold and clammy. ● Pinpoint pupils. ● Dusky nails and lips. Naloxone hydrochloride is an opioid antagonist which blocks opiate receptors in the brain and other parts of the body (drugs.com, 2023). By occupying the receptor and blocking the action of the opioid, effects of naloxone reverse opioid effects by competing for opioid sites in the central nervous system, with a great affinity for the µu receptor (drugs.com, 2023). Naloxone nasal inhalation kits are widely accepted for opioid reversal in emergent situations (Skolnick, 2018). The Substance Abuse and Mental Health Services Administration (SAMHSA) oversees the accreditation and standards for opioid treatment programs (OTPs). Many medication-assisted treatment (MAT) medications in opioid addiction are regulated under the CSA (SAMHSA, 2022a). The Drug Addiction Treatment Act of 2000 (DATA 2000 Act) permits physicians who meet set qualifications to manage opioid dependency with FDA-approved medications, such as buprenorphine, in treatment settings
agents in combination with MAT and appropriate and continued patient counseling (FDA, 2022d).
Patients at high risk of harm, such as pregnant women or those with substance abuse disorder, may require coordination with treatment experts. Withdrawal symptoms are especially concerning in pregnant patients due to the risks to the mother and fetus. It is crucial to ensure patients receive appropriate encouragement and psychosocial support, including consultations with mental health providers and treatment for opioid use disorder as needed. Reassure patients that most people have improved function, without worse pain, after tapering opioids. In addition, some patients experience less pain after a taper, even though the pain may worsen initially. Self-Assessment Quiz Question #5 Any tapering schedule must be patient-specific to minimize withdrawal symptoms. The CDC recommends what percentage while maintaining adequate pain management?
a. 10% decrease of the initial dose per week. b. 15% decrease of the initial dose per week. c. 25% decrease of the initial dose per week. d. 45% decrease of the initial dose per week.
other than OTPs (see Table 9). The DATA 2000 Act allows physicians to obtain a waiver (i.e., DEA-X) to treat opioid use disorder with Schedules III, IV, and V medications (such as buprenorphine alone or in combination) that the FDA has approved for this indication (SAMHSA, 2022b). Qualified practitioners can offer buprenorphine, a medication approved by the FDA, to treat OUD. The DATA 2000 Act and the Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act of 2018 expands the use of medication-assisted treatment using buprenorphine to additional practitioners in various settings (SAMHSA, 2022c). Qualified practitioners include physicians, NPs, physician assistants (PAs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse- midwives (CNMs). The John S. McCain Opioid Addiction Prevention Act (S.724, 116) established a new registration requirement for clinicians who are licensed to prescribe controlled substances in schedules II, III, or IV. Specifically, a practitioner must agree to limit the supply of opioids prescribed for the initial treatment of acute pain as a condition of obtaining or renewing a registration through the DEA. An opioid approved and prescribed for addiction treatment is not subject to the limit (govtrack.us, 2019). Evidence-based strategies can assist in the prevention of substance use disorder. The goal of 911 Good Samaritan laws is to reduce barriers for individuals who notify authorities about overdoses through limited immunity and other drug charges (CDC, 2022). Syringe programs are community-based programs that provide linkages to access to medical, mental health, and social services, in addition to treatment and injection equipment (CDC, 2022).
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