Some patient populations and patients with certain conditions require closer monitoring and counseling before initiation and during chronic pain treatment. For example, patients receiving other central nervous system depressants, especially benzodiazepines, require special attention because of an increased risk of adverse events, including increased sedation, confusion, difficulty driving or performing other tasks requiring high concentration levels, respiratory depression, and overdose. It is also necessary to assess how the patient uses work equipment that requires precise motor control, heavy machinery, or chemical or biohazardous materials. Pregnant individuals also require an enhanced level of caution because chronic opioid use during pregnancy increases the risk of harm to the newborn, specifically neonatal opioid withdrawal syndrome. Further, these medications must be used cautiously in breastfeeding individuals because some opioids can be transferred to breast milk and may cause sedation or respiratory depression in the nursing infant. Finally, in elderly patients, clinicians should consider employing a lower starting dose, a slower titration period, and a longer dosing interval with more frequent monitoring. Individuals with psychiatric disorders are at increased risk of adverse events associated with chronic opioid therapy. Untreated depression and other mental health disorders place patients at increased risk for misuse and abuse of opioid analgesics, including addiction and overdose. In addition, untreated depression may interfere with pain resolution. In cases where
the opioid dosage increases, the prescriber should educate the patient on the risk of cognitive impairment that can negatively impact their ability to drive or perform other activities. Evidence-based practice! Is exercise effective in treating long-lasting low back pain? Long-lasting (chronic) low back pain is a common cause of disability worldwide and is expensive in terms of healthcare costs and lost working hours. Exercise therapy aims to increase muscle and joint strength, improve muscle function and range of motion, reduce pain and disability, speed recovery, and return the patient to their usual activities. Examples of exercise therapies include general physical fitness programs delivered in a group setting, aerobic exercise in the form of walking programs, and strengthening specific muscles or groups of muscles to increase core stability. Hayden et al. (2021) conducted a systematic review. They found moderate-certainty evidence that exercise treatment is more effective than no treatment, usual care, or placebo for pain intensity and functional limitation outcomes. That is, exercise may be more effective for pain and is probably more effective for disability than common treatments in the short and medium term. ● Accidental ingestion of ER/LA opioid analgesics can result in a fatal overdose, especially in children. (Note: Accidental pet ingestion has also led to deadly doses.) ● Prolonged ER/LA opioid analgesics use during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life threatening if not recognized and treated. In prolonged opioid use in pregnant women, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure appropriate treatment will be available. ● Initiation of CYP 3A4 inhibitors (or discontinuing medications that induce CYP 3A4) can result in a fatal overdose. Note : While many ER/LA opioid analgesics are FDA-approved (at specific dosages) for opioid-naive or non- opioid-tolerant patients, current guidelines for chronic pain management do not recommend these products for patients (Dowell et al., 2016); therefore, those doses are not provided above. It is recommended to stop all other around-the-clock opioid drugs upon initiation of a new ER/LA product.
Considerations for extended-release and long-acting (er/la) opioids The FDA advises that extended-release and long-acting (ER/ LA) opioid analgesics be reserved for patients when alternative treatment options are ineffective, not tolerated, or inadequate to provide sufficient pain relief (FDA, 2018). Before prescribing these products, review FDA-approved REMS programs, medication guides, and black box warnings (BBW) (FDA, 2021). These products, listed in Table 7, are not for acute pain, pain that is mild or not expected to persist for an extended period, or use on an as-needed basis. In addition, the FDA-approved BBWs on these products advise clinicians of the following:
● ER/LA opioid analgesics expose users to addiction, abuse, and misuse risks, which may lead to overdose and death. Assess each patient’s risk before prescribing and regularly monitor the development of these behaviors and conditions. ● Life-threatening severe or fatal respiratory depression may occur. Monitor closely, primarily upon initiation and following a dose increase. Instruct patients to swallow (rather than chew) ER/LA opioid analgesics to avoid exposure to/ ingestion of a potentially fatal dose.
Table 7. Common Opioids for Chronic Pain Management
Available Oral Strengths
Medication
Dosage
Clinical Considerations
Hydrocodone, extended- release tablets • Zohydro ER
Tablets: • 10 mg • 15 mg • 20 mg • 30 mg • 40 mg • 50 mg
Initiate: • 10 mg every 12 hours. • Titrate by 10 mg every 12 hours as needed every 7 to 10 days.
The conversion factor for daily oral opioids to Zohydro: • Hydrocodone: 1
• Oxycodone: 1 • Methadone: 1 • Oxymorphone: 2 • Hydromorphone: 2.67 • Morphine: 0.67 • Codeine: 0.1
Please do not use this information to convert Zohydro to other opioids, as it will result in overestimation and possible fatal overdose. During treatment with extended-release formulations, immediate-release formulations may be required for breakthrough pain.
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