Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 4
Taylor is a 30-year-old plumber who is currently on medical leave after a work-related accident. He required surgery on his ankle that involved implantable hardware. Taylor was prescribed a short-acting opioid after each surgery, which he has continued to use due to difficulty completing his prescribed physical therapy. He is requesting an ER/LA opioid since the short-acting medication, he says, is not relieving his pain completely between doses. He says friends have suggested that a long-acting opioid would be easier to use and would provide him more steady pain relief.
1. What options exist prior to prescribing a trial of ER/LA medication?
2. What functional goal would be reasonable to discuss prior to a pain agreement with Zeke?
3. What cautions would you provide to this patient if you decided to give a trial of an ER/LA opioid?
The development of pain management programs has led to new strategies to address pain of all types in patients across multiple disciplines. The following medications are currently used to assist practitioners in the treatment of OUD. Methadone Methadone is one of the most common medicines to treat OUD. It is an opioid agonist and can only be prescribed and dispensed in licensed methadone clinics for the treatment of OUD. Methadone therapy for OUD typically requires frequent visits in conjunction with an established opioid treatment program and may be inconvenient or feel stigmatizing for some patients. Methadone was first developed and used as a pain reliever in 1947. Methadone maintenance has been evaluated since its development in 1964 as a medical response to the post–World War II heroin epidemic in New York City. 124 Prior to the release of buprenorphine, methadone was the gold standard for treatment of opiate addiction. Methadone is a full opioid agonist and retains most of the undesirable effects associated with opioids, including respiratory depression, thereby making it necessary to be managed by a trained health professional. Currently, methadone is typically dosed daily and through an approved clinic. In limited cases patients may be allowed to take methadone at home between program visits. The length of methadone treatment should be a minimum of 12 months with some patients requiring long-term maintenance. 125 Buprenorphine Buprenorphine is an increasingly popular treatment for OUD. It was approved in 2002 for the treatment of OUD and differs from methadone in that buprenorphine is only a partial agonist and has less potential for side effects and overdose injury as compared to methadone. One of the most important advantages of buprenorphine is its ceiling effect
on respiratory depression. As described earlier, respiratory depression frequently leads to hypoxia and arrest in many opioid overdoses. Buprenorphine has very little risk for respiratory depression, and this has made it increasingly favored and more suitable for its initiation in the outpatient arena. Unlike methadone, the lack of required daily visits to a treatment center can also be an advantage. Another advantage of buprenorphine is the availability of long-acting injectable or implantable formulations that carry a low risk of diversion and can be managed as a monthly visit. Some patients still prefer methadone over buprenorphine. Both methadone and buprenorphine are first line agents for the treatment of OUD in pregnancy. 126 Previously, buprenorphine could only be prescribed and dispensed by a certified provider who has a Drug Enforcement Agency license and has undergone training and/or qualifies for a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver. This list included physicians, nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse-midwifes (CNMs). This license was commonly referred to an “x-waiver” as, after a successful application was submitted, a new DEA card was provided with an “x” before the number, designating the provider as approved to prescribe buprenorphine. It is important to note that any DEA licensed practitioner could order buprenorphine during treatment of OUD during inpatient hospitalization, as the x-waiver was only necessary for prescription authority. The x-waiver is no longer necessary to prescribe buprenorphine for the treatment of OUD . On December 29, 2022, the Consolidated Appropriations Act of 2023 enacted a new one-time, 8-hour training requirement for all DEA-registered practitioners on the treatment and management of patients with opioid or other substance use disorders. 127
National Institutes of Health HEAL Initiative® Helping to End Addiction Long-term initiative® is an effort to stem the national opioid public health crisis. NIH is a research program that optimizes the delivery of services for individuals with opioid use disorders, mental health disorders, and suicide risk. 130 Long term solutions for the evolving opioid crisis include the following: • Partnering with communities to evaluate implementation strategies • Intervening in communities to prevent opioid use for at-risk individuals • Understanding ways to help opioid-exposed people while uncovering long-term effects • Developing innovative treatment in all aspects of opioid addiction • Testing a range of nonopioid pain treatments for use in clinical practice • Uncovering early-stage development of non- opioid pain treatment MOUD: Medications for Opioid Use Disorder The primary analgesic effect of opioids has been useful in the treatment of painful conditions across many disciplines. However, this has led to increased use of this type of medicine and, as previously discussed, has triggered unintended side effects and complications such as dependence. Many patients who become habituated to these drugs do not use the drugs recreationally or for pleasure, but they use them increasingly to avoid pain and dysphoria related to withdrawal in an attempt to feel “normal.” Recent initiatives have sought to better educate all practitioners on the effects of opioid medicines and to define strategies that are considered responsible and effective for patients. Multiple programs and processes have been created to treat substance use disorder (SUD) and opioid use disorder (OUD) specifically.
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