Developing a Safe Opioid Treatment Plant for Managing Chronic Pain ________________________________
Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplin- ary clinical team, they serve as cultural brokers who ultimately enhance the clinical encounter. In any case in which informa- tion regarding treatment options and medication/treatment measures are being provided, the use of an interpreter should be considered. Print materials are also available in many languages, and these should be offered whenever necessary.
Healthcare providers should use caution when prescribing opioids concurrently with benzodiazepines whenever pos- sible [1]. Combining benzodiazepines with opioids is unsafe because both classes of drug cause central nervous system depression and sedation and can decrease respiratory drive—the usual cause of overdose fatality. If a benzodiazepine is to be discontinued, the clinician should taper the medication gradu- ally, because abrupt withdrawal can lead to rebound anxiety and complications such as hallucinations, seizures, delirium tremens, and, in rare instances, death. The rate of tapering should be individualized [1]. Prescribers should be knowledgeable of federal and state opioid prescribing regulations. Issues of equianalgesic dosing, close patient monitoring during all dose changes, and cross-tolerance with opioid conversion should be considered. If necessary, treatment may be augmented, with preference for nonopioid and immediate-release opioids over extended-release/long- acting (ER/LA) opioid formulations. Taper opioid dose when no longer needed [7]. PERIODIC REVIEW AND MONITORING When implementing a chronic pain treatment plan that involves the use of opioids, the patient should be frequently reassessed for changes in pain origin, health, and function [4]. This can include input from family members and/or the state prescription drug monitoring program. Prescription drug monitoring programs are one of the most effective measures for reducing opioid analgesic diversion and abuse, but their efficacy is undermined by inconsistent use [6]. During the initiation phase and during any changes to the dosage or agent used, patient contact should be increased. Decisions regard- ing the continuation, modification, or termination of opioid therapy for pain should be based on evaluation of the patient’s progress and the absence of substantial risks or adverse events [4]. At every visit, chronic opioid response may be monitored according to the 5 A’s [8]: • Analgesia
INITIATING A TRIAL OF OPIOID THERAPY
Opioid therapy should be presented as a trial for a pre-defined period (e.g., ≤30 days). As noted, the goals of treatment should be reasonable improvements in pain, function, depression, anxiety, and avoidance of unnecessary or excessive medication use [4]. The treatment plan should describe therapy selection, measures of progress, and other diagnostic evaluations, consul- tations, referrals, and therapies. Opioid therapy should not be initiated without consideration by the clinician and patient of an exit strategy to be used if opioid therapy is unsuccessful [1]. In opioid-naïve patients, start at the lowest possible dose and titrate to effect. Dosages for opioid-tolerant patients should always be individualized and titrated by efficacy and tolerability. The need for frequent progress and benefit/risk assessments during the trial should be included in patient education. Patients should also have full knowledge of the warning signs and symptoms of respiratory depression. The CDC recommends that clinicians should evaluate benefits and risks with patients within one to four weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly re-evaluate benefits and risks of continued opioid therapy with patients. (https://www.cdc.gov/mmwr/volumes/71/rr/ rr7103a1. htm. Last accessed October 24, 2024.) Strength of Recommendation/Level of Evidence : A4 (Most patients should receive based on clinical experience and observations, observational studies with important limitations, or randomized clinical trials with several major limitations)
• Affect (i.e., patient mood) • Activities of daily living • Adverse or side effects • Aberrant drug-related behaviors
ASSESSMENT DURING ONGOING OPIOID
16
MDNJ1525
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