Substance Use Disorders and Pain Management: MATE Act Training _ _______________________________
potentially leading to oversedation and respiratory depression as buprenorphine’s partial agonist effect lessens. For patients receiving naltrexone for opioid use disorder, short-term use of higher-potency nonopioid analgesics (e.g., NSAIDs) can be considered to manage severe acute pain. Patients receiving methadone for opioid use disorder who require additional opioids as treatment for severe acute pain management should be carefully monitored, and when feasible should optimally be treated by a clinician experienced in the treatment of pain in consultation with their opioid treatment program [150]. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder (2020 Focused Update) provides additional recommen- dations for the management of patients receiving medications for opioid use disorder who have planned surgeries for which nonopioid therapies are not anticipated to provide sufficient pain relief [150]. Informed Consent and Treatment Agreements The initial opioid prescription is preceded by a written informed consent or “treatment agreement” [132]. This agreement should address potential side effects, tolerance and/or physical dependence, drug interactions, motor skill impairment, limited evidence of long-term benefit, misuse, dependence, addiction, and overdose. Informed consent documents should include information regarding the risk/ benefit profile for the drug(s) being prescribed. The prescribing policies should be clearly delineated, including the number/ frequency of refills, early refills, and procedures for lost or stolen medications. The treatment agreement also outlines joint physician and patient responsibilities. The patient agrees to using medica- tions safely, refraining from “doctor shopping,” and consent- ing to routine urine drug testing (UDT). The prescriber’s responsibility is to address unforeseen problems and prescribe scheduled refills. Reasons for opioid therapy change or dis- continuation should be listed. Agreements can also include sections related to follow-up visits, monitoring, and safe storage and disposal of unused drugs. 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 [132]. This can include input from family members and/or the state PDMP. During the initiation phase and during any changes to the dosage or agent used, patient contact should be increased. At every visit, chronic opioid response may be monitored according to the “5 A’s” [132; 152]: • Analgesia
Signs and symptoms that, if present, may suggest a problem- atic response to the opioid and interference with the goal of functional improvement include [153; 154]: • Excessive sleeping or days and nights turned around • Diminished appetite • Short attention span or inability to concentrate • 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 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 [132]. Satisfactory therapy is indicated by improvements in pain, function, 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. Involvement of Family
Family members of the patient can provide the clinician with valuable information that better informs decision making regarding continuing opioid therapy. Family members can observe whether a patient is losing control of his or her life or becoming less functional or more depressed during the course of opioid therapy. They can also provide input regard- ing positive or negative changes in patient function, attitude, and level of comfort. The following questions can be asked of family members or a spouse to help clarify whether the patient’s response to opioid therapy is favorable or unfavor- able [153; 154]: • Is the person’s day centered around taking the opioid medication? Response can help clarify long-term risks and benefits of the medication and identify other treatment options. • Does the person take pain medication only on occasion, perhaps three or four times per week? If yes, the likelihood of addiction is low. • Have there been any other substance (alcohol
or drug) abuse problems in the person’s life? An affirmative response should be taken into consideration when prescribing.
• Does the person in pain spend most of the day resting, avoiding activity, or feeling depressed? If so, this suggests the pain medication is failing to promote rehabilitation. Daily activity is essential, and the patient may be considered for enrollment in a graduated exercise program.
• Activities of daily living • Adverse or side effects • Aberrant drug-related behaviors • Affect (i.e., patient mood)
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