_______________________________ Developing a Safe Opioid Treatment Plan for Managing Chronic Pain
In principle, and ideally in practice, UDTs are a worthwhile element of effective pain management and pharmacovigilance when used to enhance the diagnostic and therapeutic objec- tives of pain therapy. However, immunoassay screens have high false-positive and false-negative rates and only provide qualita- tive information about a select number of drug classes [17]. As a side note, cannabis use by chronic pain patients receiving opioid therapy has traditionally been viewed as a treatment agreement violation that is grounds for termination of opioid therapy. However, some now argue against cannabis use as a rationale for termination or substantial treatment and monitor- ing changes, especially considering the increasing legalization of medical use at the state level [20]. In addition, there is a substantive and growing body of research confirming cannabis efficacy (and opioid-sparing effects) in chronic pain conditions, including neuropathic pain, cancer pain, fibromyalgia, and headache pain [21; 22; 23; 24; 25].
• Risk factors, signs, and symptoms of overdose and opioid-induced respiratory depression, gastrointestinal obstruction, and allergic reactions • The risks of falls, using heavy machinery, and driving • Warning and rationale to never share an opioid analge- sic • Rationale for secure opioid storage • Warning to protect opioids from theft • Instructions for disposal of unneeded opioids, based on product-specific disposal information DISPOSAL OF OPIOIDS There are no universal recommendations for the proper disposal of unused opioids, and patients are rarely advised of what to do with unused or expired medications. According to the Office of National Drug Control Policy, most medications that are no longer necessary or have expired should be removed from their containers, mixed with undesirable substances (e.g., cat litter, used coffee grounds), and put into an impermeable, nondescript container (e.g., disposable container with a lid or a sealed bag) before throwing in the trash [27]. The FDA recom- mends that most opioid medications, including oxycodone/ acetaminophen (Percocet), oxycodone (OxyContin tablets), and transdermal fentanyl (Duragesic Transdermal System), be flushed down the toilet instead of thrown in the trash [27]. Disposal by flushing down the toilet provides immediate and definitive elimination of safety hazards from intentional use or accidental exposure involving opioid products. All transdermal patch opioid products should be flushed down the toilet after folding in half by adhesive side against adhesive side [28]. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so. Flushing unused medications has been the subject of controversy, with some state govern- ments and boards recommending against the practice due to pollution concerns and effects on waterways and wildlife [29]. The American Medical Association recommends the follow- ing three steps to promote the safe storage and disposal of opioids [30]: • Educate patients about the safe use of opioids, includ- ing not sharing prescriptions with others. • Remind patients that medications should be stored out of the reach of children and in a safe place—preferably locked—to prevent other family members and visitors from taking them. • Talk to patients about the most appropriate way to dispose of expired, unwanted, and unused medications. The preferred option is that unwanted or unused pills, liquids or other medications should be disposed of in a local “take-back” or mail-back program or medication drop box at a police station, pharmacy, or authorized collection site. Contact your state law enforcement agency or visit https://www.dea.gov to determine if a program is available in your area.
PATIENT AND CAREGIVER EDUCATION
SAFE USE OF OPIOIDS Patients and caregivers should be counseled regarding the safe use and disposal of opioids. As part of its mandatory Risk Evaluation and Mitigation Strategy (REMS) for ER/ LA opioids, the U.S. Food and Drug Administration (FDA) developed a patient counseling document with information on the patient’s specific medications, instructions for emergency situations and incomplete pain control, and warnings not to share medications or take them unless prescribed [7]. This has since been replaced with the Patient Counseling Guide from the Opioid Analgesics REMS Program Companies (RPC), a collaboration of companies to implement a single shared REMS. An updated copy of the Patient Counseling Guide may be accessed online at https://www.opioidanalgesicrems. com/Resources/Docs/patient_counseling_document.pdf [26]. When prescribing opioids, clinicians should provide patients with the following information and instructions [7; 26]: • Product-specific information • Taking the opioid as prescribed • Importance of dosing regimen adherence, managing missed doses, and prescriber contact if pain is not controlled • Warning and rationale to never break or chew/crush tablets or cut or tear patches prior to use • Warning and rationale to avoid other central nervous system depressants, such as sedative-hypnotics, anxiolyt- ics, alcohol, or illicit drugs • Warning not to abruptly halt or reduce the opioid without physician oversight of safe tapering when discontinuing • The potential of serious side effects or death
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MDNJ1525
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