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 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 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, sleep- disordered breathing, 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 50 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
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Book Code: TN24CME
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