Opioid Safety: Balancing Benefits and Risks _ _____________________________________________________
ASSESSING RISK AND ADDRESSING HARMS OF OPIOID USE Recommendation 8 Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone (recommendation category: A, evidence type: 4). Implementation Considerations Clinicians should ask patients about their drug and alcohol use and use validated tools or consult with behavioral special- ists to screen for and assess mental health and substance use disorders. When considering initiating long-term opioid therapy, clini- cians should ensure that treatment for depression and other mental health conditions is optimized, consulting with behav- ioral health specialists when needed. Clinicians should offer naloxone when prescribing opioids, particularly to patients at increased risk for overdose, includ- ing patients with a history of overdose, patients with a his- tory of substance use disorder, patients with sleep-disordered breathing, patients taking higher dosages of opioids (e.g., ≥50 MME/day), patients taking benzodiazepines with opioids (see Recommendation 11), and patients at risk for returning to a high dose to which they have lost tolerance (e.g., patients undergoing tapering or recently released from prison). Practices should educate patients on overdose prevention and naloxone use and offer to provide education to members of their households. Naloxone co-prescribing can be facilitated by clinics or practices with resources to provide naloxone training and by collabora- tive practice models with pharmacists or through statewide protocols or standing orders for naloxone at pharmacies. Resources for prescribing naloxone in primary care and emer- gency department settings can be found through Prescribe to Prevent at https://prescribetoprevent.org; additional resources are at https://samhsa.gov. In part because of concerns about cost of naloxone and access for some patients and reports that purchasing of naloxone has in some cases been required to fill opioid prescriptions, including for patients without a way to afford naloxone, this recommendation specifies that naloxone should be offered to patients. To that end, clinicians, health systems, and payers can work to ensure patients can obtain naloxone, a potentially lifesaving treatment. Clinicians should avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing when possible to minimize risk for respiratory depression.
When making decisions about whether to initiate opioid therapy for pain during pregnancy, clinicians and patients together should carefully weigh benefits and risks. For preg- nant people already receiving opioids, clinicians should access appropriate expertise if tapering is being considered because of possible risk to the pregnant patient and to the fetus if the patient goes into withdrawal (see Recommendation 5). For pregnant people with opioid use disorder, medication for opioid use disorder (buprenorphine or methadone) is the recommended therapy and should be offered as early as pos- sible in pregnancy to prevent harms to both the patient and the fetus (see Recommendation 12). Clinicians should use additional caution and increased moni- toring (see Recommendation 7) to minimize risks of opioids prescribed for patients with renal or hepatic insufficiency and for patients aged ≥65 years. Clinicians should implement inter- ventions to mitigate common risks of opioid therapy among older adults, such as exercise or bowel regimens to prevent constipation, risk assessment for falls, and patient monitoring for cognitive impairment. For patients with jobs that involve potentially hazardous tasks and who are receiving opioids or other medications that can negatively affect sleep, cognition, balance, or coordination, clinicians should assess patients’ abilities to safely perform the potentially hazardous tasks (e.g., driving, use of heavy equipment, climbing ladders, working at heights or around moving machinery, or working with high-voltage equipment). Clinicians should use prescription drug monitoring program (PDMP) data (see Recommendation 9) and toxicology screen- ing (see Recommendation 10) as appropriate to assess for concurrent substance use that might place patients at higher risk for opioid use disorder and overdose. Clinicians should provide specific counseling on increased risks for overdose when opioids are combined with other drugs or alcohol (see Recommendation 2) and ensure that patients are provided or receive effective treatment for substance use disorders when needed (see Recommendation 12). Although substance use disorder can alter the expected benefits and risks of opioid therapy for pain, patients with co-occurring pain and substance use disorder require ongoing pain management that maximizes benefits relative to risks. (See Recommendation 12 Pain Management for Patients with Opioid Use Disorder for additional considerations specific to these patients.) If clinicians consider opioid therapy for chronic pain for patients with substance use disorder, they should discuss increased risks for opioid use disorder and overdose with patients, carefully consider whether benefits of opioids out- weigh increased risks, and incorporate strategies to mitigate risk into the management plan, such as offering naloxone and increasing frequency of monitoring (see Recommendation 7).
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