Only HCPs with experience and knowledge of methadone should prescribe it (only for severe pain unrelieved by other opioids) or else seek expert consultation. 38 Dual-mechanism opioids may control pain with less opioid, and opioid-sparing techniques, such as combining therapeutics should be considered. Certain cautions are necessary for special populations. Women should be informed of the risks of long-term opioid therapy during pregnancy to the developing fetus, including neonatal opioid withdrawal syndrome (NOWS), 13,46 birth defects, preterm delivery, poor fetal growth, and stillbirth. 13 Adults older than 65 years need cautious opioid dosing and consideration of risks that include falls, cognitive effects, interaction with other medications,
and increased sensitivity to analgesic effects. 44 Initial doses should be 25–50% lower than in those who are younger. 40 Caution is necessary when initiating and titrating opioid doses in people with renal and hepatic impairment. 47 Naloxone co-prescription is recommended with patients at higher risk of opioid overdose. This includes those with a history of overdose, history of SUD, clinical depression, opioid dosages ≥50 MME/day, concurrent benzodiazepine use, 13 or with evidence of increased risk by other measures. Clear rationale for prescribing or increasing dosages of opioids should be documented in the medical record, particularly if dosages exceed current recommended guidelines. 48 (Table 4)
The CDC guideline identified a dose limit of 90 morphine milligram equivalents (MMEs) daily after which caution is advised. 13 However, no dose is completely safe, 49 and much of the risk at higher doses appears to be associated with co-prescribed benzodiazepines. 50 Evidence is strong that prescribing opioids together with benzodiazepines increases risk for overdose, 33,51 and evidence also suggests that co-prescription of opioids and gabapentinoids may increase overdose risk. 33 Considerations for the Prescriber: Ongoing Opioid Therapy 1. Opioid medication prescriptions should be obtained from a single provider/ practice and filled by a single pharmacy.
Table 4. Items to Perform and Document in the Patient Record When Prescribing Opioid Therapy for Chronic Pain 18,32,38,52,53 1. Signed informed consent 2. Signed opioid treatment agreement(s) 3. Pain and medical history Chief complaint Treatments tried and patient response Past laboratory, diagnostic, and imaging results
Comorbid conditions (e.g., medical, substance-use, psychiatric, mood, sleep) Social history (e.g., employment, marital, family status, substance use) Pregnancy status or intent, contraceptive use
4. Results of physical exam and new diagnostic and imaging tests Review of systems Pain intensity and level of functioning One or more indications for opioid treatment Objective disease/diagnostic markers 5. Results of opioid risk assessment prior to prescribing opioids
Clinical interview or any screening instruments Personal history of SUD, mental health disorder Family history of SUD, mental health disorder Co-management or treatment referral for patients at risk for SUD Treatment or referral for patients with active OUD Treatment or referral for patients with undiagnosed depression, anxiety, other mental health disorders 6. Treatment goals for pain relief, function, quality of life 7. Treatments provided With risk-benefit analysis after considering available nonpharmacologic and non-opioid pharmacologic options All medications prescribed (including the date, type, dose, and quantity) All prescription orders for opioids and other controlled substances whether written or telephoned 8. Prescription of naloxone, if provided, and rationale 9. Results of ongoing monitoring toward pain management and functional goals
10. Presence and treatment of adverse events 11. Results of initial and ongoing PDMP checks
Consider risk for dangerous drug-drug interactions Consider risk for misuse with opioids Collaborate on transition with primary prescriber if opioids previously prescribed
12. Results of initial and ongoing UDT 13. Counseling and instructions to the patient and significant others Directions for medication use Ongoing discussions of risks and benefits
Adherence to prescribed therapies, including results of UDT and PDMP checks Actions taken regarding aberrant medication use (e.g., document results, collaborate with multidisciplinary team, institute taper)
14. Referrals given and notes on consultations for specialists in pain, SUD, mental-health, and medical comorbidities 15. Notes on continuing, revising, or discontinuing opioid therapy (e.g., titrate, rotate, taper, OUD management) 16. Authorization for release of information to other treatment practitioners SUD = substance-use disorder OUD = opioid-use disorder; PDMP = prescription drug-monitoring programs; UDT = urine drug testing
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