Substance Use Disorders and Pain Management: MATE Act Training _ _______________________________
Concurrent Use of Benzodiazepines In 2019, 16% of persons who died of an opioid overdose also tested positive for benzodiazepines, a class of sedative medica- tion commonly prescribed for anxiety, insomnia, panic attack, and muscle spasm [159]. Benzodiazepines work by raising the level of GABA in the brain. Common formulations include diazepam, alprazolam, and clonazepam. Combining benzodi- azepines 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. Both classes have the potential for drug dependence and addiction. The CDC recommends that healthcare providers use particular caution prescribing benzodiazepines concurrently with opioids [125; 127]. If a benzodiazepine is to be discontinued, the clini- cian should taper the medication gradually, because abrupt withdrawal can lead to rebound anxiety and complications such as hallucinations, seizures, delirium tremens, and, in rare instances, death. A commonly used tapering schedule is a reduction of the benzodiazepine dose by 25% every one to two weeks [125; 127]. Consultation and Referral It is important to seek consultation or patient referral when input or care from a pain, psychiatry, addiction, or mental health specialist is necessary. Clinicians who prescribe opi- oids should become familiar with opioid addiction treatment options (including licensed opioid treatment programs for methadone and office-based opioid treatment for buprenor- phine) if referral is needed [132]. Ideally, providers should be able to refer patients with active substance abuse who require pain treatment to an addiction professional or specialized program. In reality, these special- ized resources are scarce or non-existent in many areas [132]. Therefore, each provider will need to decide whether the risks of continuing opioid treatment while a patient is using illicit drugs outweigh the benefits to the patient in terms of pain control and improved function [160]. Medical Records As noted, documentation is a necessary aspect of all patient care, but it is of particular importance when opioid prescribing is involved. All clinicians should maintain accurate, complete, and up-to-date medical records, including all written or tele- phoned prescription orders for opioid analgesics and other controlled substances, all written instructions to the patient for medication use, and the name, telephone number, and address of the patient’s pharmacy [132]. Good medical records demonstrate that a service was provided to the patient and that the service was medically necessary. Regardless of the treatment outcome, thorough medical records protect the prescriber.
Patient Education on the Use and Disposal of Opioids
Patients and caregivers should be counseled regarding the safe use and disposal of opioids. As part of its mandatory Risk Eval- uation and Mitigation Strategy (REMS) for extended-release/ long-acting opioids, the FDA has developed a patient counsel- ing document with information on the patient’s specific medi- cations, instructions for emergency situations and incomplete pain control, and warnings not to share medications or take them unprescribed [134]. A copy of this form may be accessed online at https://www.fda.gov/media/114694/download. When prescribing opioids, clinicians should provide patients with the following information [134]: • 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, anxiolytics, 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 • 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 analgesic
• Rationale for secure opioid storage • Warning to protect opioids from theft
• Instructions for disposal of unneeded opioids, based on product-specific disposal information There are no universal recommendations for the proper dis- posal of unused opioids, and patients are rarely advised of what to do with unused or expired medications [161]. According to the FDA, 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 [162]. Any personal information should be obscured or destroyed. The FDA recommends that certain medications, including oxycodone/acetaminophen (Percocet), oxycodone (OxyContin tablets), and transdermal fentanyl (Duragesic Transdermal System), be flushed down the toilet
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