_______________________________ Developing a Safe Opioid Treatment Plant for Managing Chronic Pain
THERAPY Signs and symptoms that, if present, may suggest a problem- atic response to the opioid and interference with the goal of functional improvement include [8]: • Excessive sleeping or days and nights turned around • Diminished appetite • Inability to concentrate or short attention span • Mood volatility, especially irritability • Lack of involvement with others • Impaired functioning due to drug effects • Use of the opioid to regress instead of re-engaging in life • Lack of attention to hygiene and appearance • Escalation of pain and/or pain medication dose • Increasing number of medications prescribed to treat the side effects of opioids The decision to continue, change, or terminate opioid therapy is based on progress toward treatment objectives and absence of adverse effects and risks of overdose or diversion [4]. Sat- isfactory therapy is indicated by improvements in pain, func- tion, and quality of life. Brief assessment tools to assess pain and function may be useful, as may UDTs. Treatment plans may include periodic pill counts to confirm adherence and minimize diversion. VIGIL VIGIL is the acronym for a five-step risk management strategy designed to empower clinicians to appropriately prescribe opioids for pain by reducing regulatory concerns and to give pharmacists a framework for resolving ambiguous opioid analgesic prescriptions in a manner that preserves legitimate patient need while potentially deterring diverters. The com- ponents of VIGIL are: • Verification: Is this a responsible opioid user? • Identification: Is the identity of this patient verifiable? • Generalization: Do we agree on mutual responsibilities and expectations? • Interpretation: Do I feel comfortable allowing this person to have controlled substances? • Legalization: Am I acting legally and responsibly? The foundation of VIGIL is a collaborative prescriber/phar- macist relationship [9; 10].
Current Opioid Misuse Measure The Current Opioid Misuse Measure (COMM) is a 17-item patient self-report assessment designed to help clinicians iden- tify misuse or abuse in patients with chronic pain. Unlike the ORT and the SOAPP-R, the COMM identifies aberrant behav- iors associated with opioid misuse in patients already receiving long-term opioid therapy [11]. Sample questions include: In the past 30 days, how often have you had to take more of your medication than prescribed? In the past 30 days, how much of your time was spent thinking about opioid medications (e.g., having enough, taking them, dosing schedule)? Pain Assessment and Documentation Tool Guidelines by the FSMB and the Joint Commission stress the importance of documentation from both a healthcare quality and medicolegal perspective. Research has found widespread deficits in chart notes and progress documentation with patients with chronic pain receiving opioid therapy, and the Pain Assessment and Documentation Tool (PADT) was designed to address these shortcomings [12]. The PADT is a clinician-directed interview, with most sections (e.g., analgesia, activities of daily living, adverse events) consisting of questions asked of the patient. However, the potential aberrant drug- related behavior section must be completed by the physician based on his or her observations of the patient. The Screening, Brief Intervention, and Referral Tool (SBIRT) The Screening, Brief Intervention, and Referral Tool (SBIRT) is used for early identification and intervention for patients with substance use disorders, including opioid use disorder. Annual universal screening (S) identifies patients that may need intervention. For those who screen positive, a brief intervention (BI) questionnaire determines the level to which the patient may need intervention and allows practitioners to focus on education and awareness of health effects, with an emphasis of healthy behavioral change. The items assess the extent of problems related to drug use in several areas, includ- ing drug use-related functional impairment. The last part, referral to treatment (R), helps facilitate access to treatment and additional resources [13]. PSEUDOADDICTION Patients with inadequately treated pain can develop pseudoad- diction, characterized by aberrant drug-seeking behaviors that mimic opioid use disorder but are driven by desperation for pain relief. In these patients, aggressive complaints of needing higher dosing, openly obtaining opioid analgesics, deception, stockpiling unused medication, and unsanctioned dose escala- tions resolve with adequate pain control [14; 15]. This phenomenon is essential to understand. Many risk mitigation measures fail to consider this as a possibility, and
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MDNJ1525
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