______________________________ Strategies for Appropriate Opioid Prescribing: The Florida Requirement
is most effective [74]. NSAIDs inhibit platelet aggregation, increasing the risk of bleeding, and also can damage the mucosal lining of the stomach, leading to gastrointestinal bleeding. There is a ceiling effect to the nonopioid analgesics; that is, there is a dose beyond which there is no further analgesic effect. In addition, many side effects of nonopioids can be severe and may limit their use or dosing. Informed Consent and Treatment Agreements The initial opioid prescription is preceded by a written informed consent or “treatment agreement” [1]. This agreement should address potential side effects, tolerance and/or physical dependence, drug interactions, motor skill impairment, limited evidence of long-term benefit, misuse, dependence, addiction, and overdose. Informed consent documents should include information regarding the risk/ benefit profile for the drug(s) being prescribed. The prescribing policies should be clearly delineated, including the number/ frequency of refills, early refills, and procedures for lost or stolen medications. The treatment agreement also outlines joint physician and patient responsibilities. The patient agrees to using medications safely, refraining from “doctor shopping,” and consenting to routine urine drug testing (UDT). The prescriber’s responsibility is to address unforeseen problems and prescribe scheduled refills. Reasons for opioid therapy change or discontinuation should be listed. Agreements can also include sections related to follow-up visits, monitoring, and safe storage and disposal of unused drugs. PERIODIC REVIEW AND MONITORING When implementing a chronic pain treatment plan that involves the use of opioids, the patient should be frequently reassessed for changes in pain origin, health, and function [1]. This can include input from family members and/or the state PDMP. During the initiation phase and during any changes to the dosage or agent used, patient contact should be increased. At every visit, chronic opioid response may be monitored according to the “5 A’s” [1; 75]: • Analgesia
• Impaired functioning due to drug effects • Use of the opioid to regress instead of re-engaging in life • Lack of attention to hygiene and appearance The decision to continue, change, or terminate opioid therapy is based on progress toward treatment objectives and absence of concerning adverse effects and risks of overdose or diversion [1]. Satisfactory therapy is indicated by improvements in pain, function, and quality of life. It is important to remember that for some patients with severe chronic pain, improved function may take longer than pain control or either pain or function (not both) will improve. In some cases, preventing worsening pain/functional impairment is the best achievable outcome. Brief assessment tools to assess pain and function may be useful, as may UDTs. Treatment plans may include periodic pill counts to confirm adherence and minimize diversion. The CDC recommends that clinicians should evaluate benefits and risks with patients within one to four weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly re-evaluate benefits and risks of continued opioid therapy with patients. (https://www.cdc.gov/mmwr/volumes/71/rr/ rr7103a1.htm. Last accessed August 23, 2024.) Strength of Recommendation/Level of Evidence : A4 (Most patients should receive based on clinical experience and observations, observational studies with important limitations, or randomized clinical trials with several major limitations) Involvement of Family Family members or the partner of the patient can provide the clinician with valuable information that better informs decision making regarding continuing opioid therapy. Family members can observe whether a patient is losing control of his or her life or becoming less functional or more depressed during the course of opioid therapy. They can also provide input regarding positive or negative changes in patient function, attitude, and level of comfort. The following questions can be asked of family members or a spouse to help clarify whether the patient’s response to opioid therapy is favorable or unfavorable [76]: • Is the person’s day centered around taking the opioid medication? Response can help clarify long-term risks and benefits of the medication and identify other treatment options. • Does the person take pain medication only on occasion, perhaps three or four times per week? If yes, the likelihood of addiction is low.
• Activities of daily living • Adverse or side effects • Aberrant drug-related behaviors • Affect (i.e., patient mood)
Signs and symptoms that, if present, may suggest a problematic response to the opioid and interference with the goal of functional improvement include [76]: • Excessive sleeping or days and nights turned around • Diminished appetite • Short attention span or inability to concentrate • Mood volatility, especially irritability • Lack of involvement with others
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