Risks for development of SUD should be assessed prior to initiating treatment, particularly when treating pain with opioids. Factors that contribute to risk are many and include the following: 5,73-75 • Younger age (<30 years) • Personal history of substance misuse • Adverse social and life circumstances • Comorbid mental conditions • Social exposure to others with SUD • Exposure to parental SUD • History of trauma or childhood adversity • Obtaining CS from more than one HCP without authorization • Obtaining multiple CS from multiple sources • Use of illicit street drugs during therapeutic treatment with CS • Sleep disturbances • Mood disorders • Stress When evaluating a patient and during periodic clinical follow-up, it is important to watch for signs and symptoms of dangerous non-adherence with treatment directives. One such important characteristic is obtaining CS prescriptions from more than one prescriber, sometimes at multiple facilities (aka “doctor shopping”) although the patient has agreed to use only one prescriber and one pharmacy to fill all CS prescriptions. 76,77 Other indicators of continuing non-adherence to medical direction include taking too much medication, taking medication by the wrong route of administration, use of illicit substances, and use of unauthorized prescription drugs obtained from nonmedical sources. In addition, pay attention if the patient exhibits ongoing problems with interacting and fulfilling roles related to family, work, and personal life. Trips to the emergency department (ED) are concerning, particularly if CS are requested there and this type of medical care utilization becomes a pattern that repeats. Data show a correlation of patients frequently obtaining opioids in EDs with “pill shopping” in that 5% to 10% are already taking opioids from other providers. 17 Benzodiazepine SUD may present with particular physical signs that include: 78 • Speech problems • Incoordination • Dizziness
Any misuse can threaten the integrity of CS therapy if not addressed. Not all misuse is intentional; for example, taking an incorrect dose. Similarly, not every instance of failure to comply with medical direction indicates an SUD has developed in the patient who has lent medications to a family member or taken an extra pill. However, repeated failure to adhere to the treatment agreement along with increasingly dangerous patterns of usage call for action on the part of the HCP. These actions might include a switch to less risky treatments or medications to manage symptoms of the medical condition for which the CS was prescribed. Referral to specialists in pain, SUD treatment, or mental health may be indicated. In some cases, the patient may need to be referred entirely for specialist management and, in other cases, co-management of the patient with a specialist or specialists may be possible and advisable. If, after a risk-benefit analysis, it appears CS should be tapered, it is important to do so carefully and safely.
Patients who are discontinued or tapered non- collaboratively are at risk for acute withdrawal, pain exacerbation, anxiety, depression, suicidal ideation, self-harm, ruptured trust, opioid overdose, and seeking opioids from high-risk sources. 5,79,80 Taper without the patient’s consent is a challenging situation and the risks versus benefits of treatment should be clearly defined. If the prescriber decides that the risks of the treatment outweigh the benefits, the prescriber may need to recommend taper. One should continue to treat pain and withdrawal with pharmacologic and nonpharmacologic options. If the patient has serious mental illness, a high suicide risk, or suicidal ideation, offer or arrange for consultation with a behavioral health provider before initiating a taper. 79 Treating common comorbid mental disorders (e.g., depression, anxiety, and PTSD) can improve the likelihood of opioid tapering success and reduce dropouts. 79 Access appropriate expertise if considering opioid tapering or managing OUD during pregnancy. 79 Opioid withdrawal risks include spontaneous abortion and premature labor. For pregnant women with OUD, MOUD is preferred over detoxification. HCPs should advise patients that there is an increased risk for overdose on abrupt return to a previously prescribed higher dose. 79 One should strongly caution them that it takes as little as a week to lose tolerance. Patients should be provided with opioid overdose education and possibly offered naloxone. Taper should be slow enough to minimize opioid withdrawal, and longer duration of therapy entails slower taper (common tapers involve dose reductions of 5% to 20% every 4 weeks). Signs of withdrawal with opioids occur when stopping or decreasing doses or administering an opioid antagonist. Acute opioid withdrawal symptoms include drug craving, anxiety, restlessness, insomnia, abdominal pain or cramps, nausea, vomiting, diarrhea, anorexia, sweating, dilated pupils, tremor, tachycardia, piloerection, hypertension, dizziness, hot flashes, shivering, muscle or joint aches, runny nose, sneezing, tearing, yawning, and dysphoria. 79 Pain often worsens with withdrawal and, although the pain may be prolonged, it does tend to diminish over time for many patients. 79 If patients on high opioid dosages are unable to taper despite worsening pain and/or function, whether OUD criteria are met, HCPs may consider transitioning to buprenorphine. Buprenorphine is a partial opioid agonist that can treat pain as well as OUD, result in less opioid- induced hyperalgesia (i.e., heightened pain response), and easier withdrawal than full mu-agonist opioids, and less respiratory depression than other LA opioids. 79 Treatments for withdrawal symptoms include alpha-2 agonists clonidine and lofexidine. 79 Other medications may be NSAIDs, ACET, or topical menthol/methyl salicylate for muscle aches; trazodone for sleep disturbance; prochlorperazine, promethazine, or ondansetron for nausea; dicyclomine for abdominal cramping; and loperamide or bismuth subsalicylate for diarrhea. 79
Tapering Controlled Substances
Tapering to reduce a long-term opioid dosage or to discontinue opioid therapy can be done for the following reasons: 79 • Patient has requested to discontinue or taper doses • Pain improves • A new treatment is expected to improve pain • Pain and function are not meaningfully improved with opioids • Patient is receiving higher opioid doses without evidence of benefit • Patient has current evidence of opioid misuse • Patient experiences side effects that diminish quality of life or impair function • Patient experiences overdose or other serious event (e.g., hospitalization, injury) or has warning signs (e.g., confusion, sedation, slurred speech) for an impending event • Risk for adverse outcomes is increased through co-administration of medications (e.g., benzodiazepines) or medical conditions (e.g., lung disease, sleep apnea, liver disease, kidney disease, fall risk, advanced age) • Long-term opioid administration has been prolonged (e.g., years) and current benefit- harm balance is unclear HCPs should ensure patient understanding of tapering plan while maintaining that the plan remains patient centered . In considering whether opioids or other CS continue to meet treatment goals, evaluate risks versus benefits and avoid insisting on tapering or discontinuation when opioid use may be warranted (e.g., treatment of cancer pain, pain at the end of life, or other circumstances in which benefits outweigh risks of opioid therapy). HCPs should avoid dismissing patients from care. Instead, refer patients for medication treatment for OUD (MOUD) as described below and ensure that patients continue to receive coordinated care. 79
• Disorientation • Poor memory • Inability to concentrate • Sedation • Decreased blood pressure • Decreased respirations • Coma
As with other SUD, behavioral difficulties may include relationship conflicts, poor school or work performance, financial and/or legal issues, multiple prescribers, early medication refills, and use of the medication (in this case, benzodiazepine) together with other CNS-depressant drugs. 78
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