______________________________________________________ Opioid Safety: Balancing Benefits and Risks
INTRODUCTION Healthcare professionals should know the best clinical prac- tices in opioid prescribing, including the associated risks of opioids, approaches to the assessment of pain and function, and pain management modalities. Pharmacologic and non- pharmacologic approaches should be used on the basis of cur- rent knowledge in the evidence base or best clinical practices. Patients with moderate-to-severe chronic pain who have been assessed and treated, over a period of time, with nonopioid therapy or nonpharmacologic pain therapy without adequate pain relief, are considered to be candidates for a trial of opioid therapy. Initial treatment should always be considered indi- vidually determined and as a trial of therapy, not a definitive course of treatment [1; 2].
View the CDC’s video Prescription Opioids: Back on Track at https://www.netce.com/learning.php?page=acti vities&courseid=3207. This video highlights the risks of opioids and offers some nonopioid options for chronic pain management. inter active activity Implantable intrathecal opioid infusion and/or spinal cord stimulation may be options for severe, intractable pain. Both options require that devices or ports be implanted, with asso- ciated risks. With intrathecal opioid infusion, the ability to deliver the drug directly into the spine provides pain relief with significantly smaller opioid doses, which can help to minimize side effects (e.g., drowsiness, dizziness, dry mouth, nausea, vomiting, and constipation) that can accompany systemic pain medications that might be delivered orally, transdermally, or through an IV [3]. However, use of opioid infusion has traditionally been limited to cancer pain. With spinal cord stimulation therapy, the most challenging aspect is patient selection. In order for patients to be considered for spinal cord stimulation, other options should have been ineffective or be contraindicated. Spinal cord stimulation is indicated for severe neuropathic pain persisting at least six months [2; 3]. If opioids are used, they should be combined with nonphar- macologic therapy and nonopioid pharmacologic therapy, as appropriate. Clinicians should consider opioid therapy only if expected benefits for pain and function are anticipated to outweigh risks to the patient [4]. Opioid therapy for chronic pain should not be initiated with- out consideration by the clinician and patient on follow-up, taper, and exit strategy if opioid therapy is unsuccessful.. The goals of treatment should be established with all patients prior to the initiation of opioid therapy, including reasonable improvements in pain, function, depression, anxiety, and avoidance of unnecessary or excessive medication use. The treatment plan should describe therapy selection, measures of progress, and other diagnostic evaluations, consultations, referrals, and therapies [1; 2]. In patients who are opioid-naïve, start at the lowest possible dose and titrate to effect. Dosages for patients who are opioid- tolerant should always be individualized and titrated by efficacy and tolerability. When starting opioid therapy for chronic pain, clinicians should prescribe short-acting instead of extended- release/long-acting (ER/LA) opioid formulations [1; 2]. 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 [2].
TYPES OF PAIN AND THE ROLE OF OPIOIDS
ACUTE AND SUBACUTE PAIN Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute (less than one month) or subacute (one to three months) pain, clinicians should prescribe the lowest effective dose of immediate-release opioids in a quantity no greater than that needed for the expected duration of severe pain [2]. With postoperative, acute, or intermittent pain, analgesia often requires frequent titration, and the two- to four-hour analgesic duration with short-acting hydrocodone, morphine, and oxy- codone is more effective than extended-release formulations. Short-acting opioids are also recommended in patients who are medically unstable or with highly variable pain intensity [2]. CHRONIC NON-CANCER PAIN Nonpharmacologic therapy and nonopioid pharmacologic therapy are the preferred first-line therapies for chronic non- cancer pain. Several nonpharmacologic approaches are thera- peutic complements to pain-relieving medication, lessening the need for higher doses and perhaps minimizing side effects. These interventions can help decrease pain or distress that may be contributing to the pain sensation. Approaches include palliative radiotherapy, complementary/alternative methods, manipulative and body-based methods, and cognitive/behav- ioral techniques. The choice of a specific nonpharmacologic intervention is based on the patient’s preference, which, in turn, is usually based on a successful experience in the past [2].
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