• Hormonal deficiencies • Pruritis • Myoclonus • Irritability • Respiratory depression
In 2020 the Tennessee Department of Health issued the latest edition of its clinical practice guidelines for the outpatient management of chronic non-malignant pain. 41 The guidelines can serve as a resource for any prescriber who may be utilizing opioid medications in the treatment of patients with chronic pain, with an emphasis on the avoidance of adverse outcomes or addiction. The guidelines provide detailed recommendations when considering, initiating and continuing the use of opioid medications in the treatment of chronic, non-malignant pain. Many useful resources are available to the prescriber within the guidelines including assessment tools, special population concerns, examples of informed consent/ patient agreements, as well as information of Emergency Department opioid prescribing guidelines and acute pain management. The guidelines may be found at: https://www. tn.gov/content/dam/tn/health/healthprofboards/ pain-management-clinic/ChronicPainGuidelines.pdf The following represents a summary of some of the key principles included in the Tennessee Chronic Pain Guidelines. Considerations for the Prescriber: Prior to the Initiation of Opioid Therapy 1. Prior treatment of pain with opioids, provided by a previous provider, does not obligate, or necessitate continued opioid treatment. 2. Non-opioid treatment modalities should be attempted prior to initiating treatment with opioid medications. 3. Telemedicine is not an appropriate modality for treatment of chronic pain with opioids (or other controlled substances). 4. Birth control methods should be discussed to avoid unintended pregnancy in women of childbearing age. 5. A thorough history, physical examination and review of a patient’s prior medical records should be completed and documented. 6. A thorough history of the patient’s painful condition should be pursued, including prior diagnostic testing and treatment attempts. 7. Risks for abuse, misuse, addiction, and diversion must be assessed. 8. A current diagnosis must be established to justify opioid medications. 9. The prescriber and patient must identify a plan that includes treatment modalities beyond opioids. 10. Goals of treatment should be established and emphasize reduction of pain for improved daily function, not necessarily complete elimination of pain. Functional goals could include improved activities of daily living, increase social participation or returning to work. To be effective, functional treatment goals should be realistic and tailored to each patient. A helpful strategy is to help the patient define SMART goals (specific, measurable, action-oriented, realistic, and time-sensitive). 42
11. Informed consent regarding the potential risks of opioid medications such as physical dependence, physical impairment, over- sedation, addiction, and death must be obtained. The guidelines include an example of an Informed Consent document. The patient should be counseled that the goal of chronic opioid therapy is to increase function and reduce pain, not to eliminate pain. Most randomized controlled trials have shown modest reductions in pain with opioids averaging 30%. A recent systematic review found that only 44.3% of patients had 50% pain relief with opioids in the short term. 43 Documentation of this discussion should be included in the medical record. The possible presence of co-occurring mental health disorders should be considered, and screening tests should be used if depression, anxiety, PTSD, current or past substance use disorder, or any other mental health conditions are suspected. Prescribers should obtain a Urine Drug Test (UDT) (or a comparable test on oral fluids) prior to initiating opioid therapy and they should access the Tennessee Controlled Substances Monitoring Database (CSMD) to obtain data about a patient’s risk of misuse, abuse or diversion of medications. 41 Considerations for the Prescriber: Initiation of Opioid Therapy 1. Written agreements/ treatment plans between patient and prescriber should define reasons for discontinuance of opioids, refill policies, lost prescription/ medication policies, safe storage of medications, intermittent drug testing and use of one pharmacy for obtaining medications. The guidelines offer an example of a patient agreement. 2. The patient must acknowledge that initiation of treatment with opioids is a therapeutic trial. 3. Treatment should begin with the lowest dose of opioids and titrate to effect. 4. Patients should be monitored closely for any evidence of abuse, misuse, or diversion. 5. Patients must acknowledge that unannounced urine drug testing is required at least twice yearly. 41 Patients initiated on a trial of opioids for chronic pain should be initiated at the lowest effective dose and titrated slowly to analgesic effect. 44 Short- acting (SA) opioids are preferred and considered safer when initiating a therapeutic trial of opioids and are often prescribed for use as needed, every 4 to 6 hours. 44,45 If patients require long-term treatment and pain is severe enough to require around-the-clock, long-acting (LA) analgesia that is not adequately relieved by IR/SA opioids or other therapies, consider a transition to ER/LA opioids with scheduled dosing. 46 Methadone for pain presents special clinical challenges due to properties that include a long and variable half-life and pain relief that wanes even though the concentration in the body remains and depresses breathing. 24
Signs of an opioid overdose include: 37,38 • Small, constricted “pinpoint pupils” • Falling asleep or loss of consciousness • Slow, shallow breathing • Choking or gurgling sounds • Limp body • Pale, blue, or cold skin • Snoring heavily and cannot be awakened • Periods of ataxic (irregular) or other sleep- disordered breathing • Trouble breathing • Dizziness, confusion, or heart palpitations Acute Pain Opioids in acute pain settings should only be prescribed for the duration of the pain at the lowest effective therapeutic dose. 13,39 Prescriptions beyond 3 days are rarely necessary, 13 while more severe episodes rarely need more than 7-14 days, although there are exceptions, and each patient should be treated as an individual. 13,40 Be aware also that localities and states may have strict regulations governing maximum duration of prescriptions for acute pain. Acute pain should not be treated with ER/LA formulations of opioids, and opioids typically are not recommended for nonspecific back pain, headaches, or fibromyalgia, if the HCP should see a patient experiencing acute pain flares with these conditions. 33 HCPs should check the PDMP ahead of prescribing opioids for acute pain whenever possible 5 and reevaluate the pain diagnosis and treatment plan if pain persists beyond the expected healing period. Chronic Pain Patients need access to appropriate and effective pain relief with a commitment to avoiding or managing adverse effects arising from treatment with CS. Some 50 million U.S. adults live with chronic daily pain, and 19.6 million experience high-impact pain that interferes with daily life and work. 5 Patients who suffer pain long term have reduced quality of life and are at risk for morbidity when pain goes untreated or is managed inappropriately. Effective pain management skills are part of quality medical practice. Effective treatment for pain does not usually involve ongoing opioid therapy, which should be reserved for patients with pain severe enough to warrant an opioid and for whom more conservative therapies would not be effective or have previously failed to be effective. 13 Numerous non-opioid pharmacologic therapies are available for pain, and these should be tried or considered, alone or in combination, before initiating long-term opioid therapy. 5 A trial of opioids, when indicated, should be part of a comprehensive treatment approach, typically in combination with one or more treatment modalities. 33
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