After Surgery (ERAS) strategies, which are system processes involving each aspect of the surgical journey that could affect recovery. 46 An important part of ERAS is multi-modal analgesia therapy to treat the pain related to surgical procedures. 47 Guidelines from an expert consensus panel provide specific recommendations for dosing oxycodone 5mg tablets for pain following common surgical procedures. 48 CDC guidelines suggest that for most painful conditions Non-opioid pain treatment Non-opioid pain management is an important tool in the war against both acute and chronic pain. The Alternatives to Opiates (ALTO) program was launched in 2016 at St. Joseph’s Regional Medical Center in Paterson, NJ. This program was novel at the time and used targeted nonopioid medications, trigger-point injections, nitrous oxide, and ultrasound-guided nerve blocks to tailor its patients’ pain management needs and avoid opioids when possible. According to their website, the hospital reduced opioid use by 50% since the inception of the program. 50 The ALTO program has matured, and other institutions have implemented similar programs. The Colorado ALTO project has a toolkit with specific recommendations for the treatment of acute and non-acute pain. (https://cha. com/wp- content/uploads/2018/04/Colorado-ALTO- Project-Clinician-Toolkit.pdf) This project, initially designed and tested on patients presenting to the ED, has categories of patients organized by pain type
(barring major surgery or trauma) a 3-day supply should be enough, although many factors must be taken into account (for example, some patients in very rural areas might live so far away from a health care facility or pharmacy that somewhat larger supplies might be justified). 49 The CDC provides resources for healthcare providers that are easily accessed on their website, https://www.cdc.gov/opioids/providers/ prescribing/index.html. within the toolkit. It can be used by all providers to treat various types of pain in the ED, inpatient and outpatient setting. Other clinical applications guides are available and include specific recommendations for treatment regimens depending on the acute complaint in the ED. The use of NSAIDs, skeletal muscle relaxants and topical medications are very common. More recent additions include the use of low dose ketamine and haloperidol in the treatment of acute pain in the Emergency Department setting. 51 The American Academy of Pain Medicine developed a clinical practice guideline for use in the treatment of pain and can be reviewed on their website. https:// painmed.org/clinical-guidelines/. A comprehensive report on pain management practices can be found on the US Department of Health and Human Services website: https://www.hhs.gov/opioids/prevention/ pain-management-options/index.html.
PATIENT EDUCATION AND SAFETY
Patient education about the effects of these medications is critical and necessary when prescribing opioids to treat acute or chronic pain. Advise both patient and family about the common side effects and best practices related to dosing. Planning should include provision of prescriptions or distribution of naloxone to use in the event of overdose or respiratory depression. In addition, whenever an opioid is prescribed, the patient and family should be educated about the safe use and storage of the medications. Safe use refers to adherence to clinician instructions about dosing, avoiding potentially dangerous drug interactions, and preventing diversion. Remind patients that opioid pain medications are frequently diverted, and opioids should be stored in a locked cabinet or other secure storage unit. If a locked unit is not available, patients should be advised to not keep opioids in an open place that is easily accessed by
others, since theft by friends, relatives, and guests is a known route by which opioids become diverted. 52 Discuss the effects that opioids might have on ability to operate a vehicle, particularly when opioids are first stared, when dosages are increased, or when other central nervous system depressants, such as benzodiazepines or alcohol, are used concurrently. Proper disposal methods should be explained. Common instructions include the recommendation to not flush medications down the sink or toilet unless the prescribing information specifically instructs to do so. Many pharmacies, health centers, police stations and other organizations have take back programs, including tamper proof drop off containers. Mixing the medicine with an undesirable substance such as coffee grounds or kitty litter for disposal in the trash is another option. 53 Commercial disposal systems such as DisposeRX have been developed and is a safe way to dispose of these medications.
SUBSTANCE USE DISORDER (SUD) AND OPIOID USE DISORDER (OUD)
Increased awareness and attention have been placed on the identification and treatment of patients who develop addiction to opioids. Substance Use Disorder (SUD) and Opioid Use Disorder (OUD) are preferred terms for patients with dependence to these drugs. This disorder was previously classified as Opioid Abuse or Opioid Dependence in DSM- IV. 54 The DSM V recognizes substance-related disorders resulting from the use of 10 separate classes of drugs, including opioids. Opioid use
disorder consists of an overpowering desire to use opioids, increased opioid tolerance, and withdrawal syndrome when discontinued. Opioid use disorder includes dependence and addiction with addiction representing the most severe form of the disorder. To confirm a diagnosis of OUD, at least two of the following should be observed within a 12-month period: 55 1. Opioids are often taken in larger amounts or over a longer period than was intended.
Book Code: CT24CME
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