Table 5. DSM-5 OUD Criteria (Continued) ● Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that’s likely to have been caused or exacerbated by the substance ● Tolerance,* as defined by either of the following: a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect b. A markedly diminished effect with continued use of the same amount of an opioid ● Withdrawal,* as manifested by either of the following: a. The characteristic opioid withdrawal syndrome b. The same—or a closely related—substance is taken to relieve or avoid withdrawal symptoms *This criterion is not met for individuals taking opioids solely under appropriate medical supervision. Severity: mild = 2–3 symptoms;
moderate = 4–5 symptoms; severe = 6 or more symptoms. 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
● 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 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.
TAPERING CONTROLLED SUBSTANCES
● 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
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
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Book Code: TN24CME
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