● Hormonal deficiencies ● Pruritis ● Myoclonus ● Irritability ● Respiratory depressionSigns 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 expected duration of the pain severe enough to require opioids and at the lowest effective therapeutic dose. 13,39 If opioids are used continuously (around the clock) for more than a few days for acute pain, clinicians should prescribe a brief taper to minimize withdrawal symptoms on discontinuation of opioids. Taper durations might need to be adjusted depending on the duration of the initial opioid prescription. 13 Tapering plans should be discussed with the patient before discharge and with clinicians coordinating the patient’s care as an outpatient. 13 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. 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 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 TherapyPrior treatment of pain with opioids, provided by a previous provider, does not obligate, or necessitate continued opioid treatment. 1. Non-opioid treatment modalities should be attempted prior to initiating treatment with opioid medications. 2. Telemedicine is not an appropriate modality for treatment of chronic pain with opioids (or other controlled substances). 3. Birth control methods should be discussed to avoid unintended pregnancy in women of childbearing age. 4. A thorough history, physical examination and review of a patient’s prior medical records should be completed and documented. 5. A thorough history of the patient’s painful condition should be pursued, including prior diagnostic testing and treatment attempts. 6. Risks for abuse, misuse, addiction, and diversion must be assessed. 7. A current diagnosis must be established to justify opioid medications. 8. The prescriber and patient must identify a plan that includes treatment modalities beyond opioids. 9. 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 10.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.
Book Code: TN24CME
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