Table 6: Recommendations for preventing or treating opioid-induced side effects 140
Constipation
Methylnaltrexone or naloxegol Prophylactic mild peristaltic stimulant (e.g. bisacodyl or senna) If no bowel movement for 48 hours, increase dose of bowel stimulant If no bowel movement for 72 hours, perform rectal exam If not impacted, provide additional therapy (suppository, enema, magnesium citrate, etc.)
Nausea or vomiting
Consider prophylactic antiemetic therapy Add or increase non-opioid pain control agents (e.g. acetaminophen) If analgesia is satisfactory, decrease dose by 25% Treat based on cause
Sedation
Determine whether sedation is due to the opioid – if so, lower opioid dose immediately Eliminate nonessential CNS depressants (such as benzodiazepines) Reduce dose by 20-30% Add or increase non-opioid or non-sedating adjuvant for additional pain relief (such as NSAID or acetaminophen)so the opioid can be reduced Change opioid Prescribe naloxone
Pruritus
Consider treatment with antihistamines Change opioid Evaluate underlying cause Eliminate nonessential CNS acting medications
Hallucination or dysphoria
Sexual dysfunction
Reduce dose Testosterone replacement therapy may be helpful (for men) Erection-enhancing medications (e.g., sildenafil)
In 2019 the FDA, recognizing the risks associated with abrupt discontinuation of opioid analgesics, required new labeling for opioid analgesics to guide prescribers about safe tapering practices. 138 The key elements include: 144 • Do not abruptly discontinue opioid analgesics in patients physically dependent on opioids. Counsel patients not to discontinue their opioids without first discussing the need for a gradual tapering regimen. • Abrupt or inappropriately rapid discontinuation of opioids is associated with serious withdrawal symptoms, uncontrolled pain, and suicide. • Ensure ongoing care of the patient and mutually agree on an appropriate tapering schedule and follow-up plan. • In general, taper by an increment of no more than 10-20% every 2-4 weeks. • Pause taper if the patient experiences significantly increased pain or serious withdrawal symptoms. • Use a multimodal approach to pain management, including mental health support (if needed). • Reassess the patient regularly to manage pain and withdrawal symptoms that emerge and assess for suicidality or mood changes. • Refer patients with complex comorbidities or substance use disorders to a specialist.
OUD is not a binary diagnosis, rather it exists as a continuum, with DSM-5 describing 3 levels of severity: • Mild OUD (2-3 criteria) • Moderate OUD (4-5 criteria) • Severe OUD (≥ 6 criteria) More than 2 million Americans have OUD, and the number is growing. 70 OUD can be effectively managed with medication-assisted treatment (MAT), but only an estimated 20% of adults with OUD currently receive such treatment. 146 Medications to treat OUD The FDA has approved three medications for treating OUD: buprenorphine, methadone, and extended-release naltrexone (Table 7). Buprenorphine and methadone can reduce opioid cravings and all three can prevent misuse. 141 Each medication has a unique mechanism of action and involve different formulations, methods of induction and maintenance, patterns of administration, and regulatory requirements. Methadone Methadone is a synthetic, long-acting opioid agonist that fully activates mu-opioid receptors in the brain. 148 This activity reduces the unpleasant/ dysphoric symptoms of opioid withdrawal, and, at therapeutic doses, it blunts the “highs” of shorter-acting opioids such as heroin, codeine, and oxycodone. Patients do not have to experience opioid withdrawal before starting methadone.
Opioid use disorder (OUD) OUD is a problematic pattern of opioid use that causes significant impairment or distress. 145 As with other chronic diseases, OUD usually involves cycles of relapse and remission. DSM-5 diagnosis of OUD is based on clinical evaluation and determination that a patient has problematic opioid use leading to clinically significant impairment or distress involving at least two of the following within a 12-month period: 145 • Opioids taken in larger amounts, or for longer periods, than intended • Persistent desire or unsuccessful attempts to control or reduce use • Significant time lost obtaining, consuming, and recovering from opioids • Craving or a strong desire or urge to use opioids • Failure to complete obligations (i.e., work, home, or school) due to opioids • Persistent or recurrent social or interpersonal problems due to opioids • Giving up enjoyable social, work, or recreational activities due to opioids • Recurrent opioid use in situations in which it is physically hazardous (e.g., driving) • Continued use despite a physical or psychological problem caused by or worsened by opioid use • Tolerance (unless opioids are being taken as prescribed) • Using opioids to prevent withdrawal symptoms (unless opioids are being taken as prescribed)
61
Powered by FlippingBook