to treat substance use disorder (SUD) and opioid use disorder (OUD) specifically. The development of pain management programs has led to new strategies to
address pain of all types in patients across multiple disciplines.
OPIOIDS AND PAIN CONTROL
Acute and chronic pain exacerbation is the cause for a large percentage of ED and primary care visits and it is estimated that over 40% of ED visits are related to pain. 27 Recent studies showed that one in five adults have chronic pain with 7.4% of adults describing chronic pain that frequently limited life or work activities (referred to as high impact chronic pain) in the past 3 months. 28 Opioids play an important role in the management of pain despite the potential dangers of use and still remains an integral tool in modern medicine. Multiple medications and non- medication regimens have been proposed for various types of acute and non-acute pain. Recent evidence suggests that non-opioid pain regimens may be as effective for moderate to severe pain as opioids. 29,30 Opioids are commonly prescribed for pain, with approximately 20% of patients presenting with non- cancer acute or chronic pain receiving an opioid in any given year, and nearly two thirds of the public reporting being prescribed an opioid for pain at some point in their lives. 31,32 Guidelines from the Centers for Disease Control and other organizations strongly recommend that only short-acting opioids be prescribed for acute pain because they reach peak effect more quickly than extended-release formulations and decrease the risk of unintentional overdose. 33 This recommendation recognizes that overdose was 5 times more likely in patients prescribed extended-release opioids compared to immediate-release opioids. 34 According to the American Medical Association (AMA), an estimated 3 to 19 percent of people who take prescription pain medications develop an addiction to them. 35 Physical dependence can readily occur after use of opioids for a few days. Up to 20% of opioid naïve patients develop long-term opioid use after just 10 days of treatment. 36 Despite the known dangers, significant variability exists in the literature as to the exact level of risk Opioid dosing Calculating a patient’s total daily dose of opioids is important to avoid potential complication. Dosing must be considered in relation to the drug's specific pharmacokinetics, the patient's unique circumstance including age, activity level, and other medication interactions. Evaluation of the patient's tolerance and expected duration of use is also necessary. The CDC offers an Opioid Guidance Mobile App that assists the provider to apply these recommendations. (https://www.cdc.gov/opioids/providers/prescribing/ ap p .html) The app includes a Morphine Milligram Equivalent (MME) calculator. It is reported that MME dosages above 50 MME/day doubles the overdose risk. 39 A summary graphic related to MME dosing can be found on the CDC website at https://www. cdc.gov/drugoverdose/pdf/calculating_total_daily_ dose-a.pdf. Providers must be cautious when using
posed by the use of prescribed opioids when prescribed by licensed professionals. A recent review even questions the severity of opioid risk in patients treated for severe chronic pain. The authors contend that there are no scientific grounds for considering alternative non-pharmacologic treatments as an adequate substitute for opioid therapy. They do believe that these alternative treatments might serve to augment opioid therapy, thereby reducing the necessary dosage of the opioid to achieve appropriate pain control. 37 The CDC Guideline for Prescribing Opioids for Chronic Pain was published in 2016 and is expected to be updated soon. This guide strongly suggests that opioids are not first line therapy and suggests establishing goals for pain and function and discussion of risks and benefits for patients seeking chronic pain relief. If use of an opioid is thought to be appropriate based on the clinician’s evaluation, certain cautions must be exercised to decrease risk of complications. The patient that continues to use controlled medications for chronic pain control should be drug tested at least annually. Concurrent sedating medication use should be limited when possible. Use of a combination of opioids and benzodiazepines are thought to be particularly dangerous due to the sedative effects. 38 The practitioner should review the prescription drug monitoring program (PDMP) data for each patient. Prescription drug monitoring programs are active in every state and are designed to facilitate the collection, analysis, and reporting of information on the prescribing, dispensing, and use of prescription drugs within each state. An overriding goal of PDMPs is to uphold both the state laws ensuring access to appropriate pharmaceutical care by citizens and the state laws deterring diversion. More information regarding PDMPs can be found at the CDC website at https://www.cdc.gov/opioids/providers/pdmps.html. calculators alone because dose is not the only relevant variable when measuring potential risk. It is beyond the scope of this review to recommend specific treatments for pain control, although many guidelines exist. It is accepted that only enough opioids should be prescribed to address the expected duration and severity of pain from an injury or procedure (or to cover pain relief until a follow-up appointment). Due to the large number of patients evaluated for acute pain in the emergency department, many articles address opioid prescribing in this particular setting. 40,41 Other resources that focus on various other clinical settings have generally recommended prescribing ≤3 days of opioids in most cases. Some have recommended ≤7 days, with some suggesting an even longer duration of treatment. 42,43,44,45 The surgical societies have adopted Enhanced Recovery
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Book Code: CT24CME
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