__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use
PATIENT RISK STRATIFICATION
Low Risk Definable physical pathology with objective signs and reliable symptoms Clinical correlation with diagnostic testing including magnetic resonance imaging, physical examination, and interventional diagnostic techniques With or without mild psychological comorbidity With or without minor medical comorbidity None or well-defined and controlled personal or family history of alcoholism or substance abuse Age 45 years or older High levels of pain acceptance and active coping strategies High motivation, willingness to participate in multimodal therapy and attempting to function at normal levels Medium Risk Significant pain problems with objective signs and symptoms confirmed by radiological evaluation, physical examination, or diagnostic interventions Moderate psychological problems, well-controlled by therapy Moderate coexisting medical disorders well controlled by medical therapy and which are not affected by chronic opioid therapy such as central sleep apnea Those who develop mild tolerance but not hyperalgesia without physical dependence or addiction Past history of personal or family history of alcoholism or substance abuse Pain involving more than three regions of the body Defined pathology with moderate levels of pain acceptance and coping strategies Willing to participate in multimodal therapy, attempting to function in their normal daily lives High Risk
Widespread pain without objective signs and symptoms Pain involving more than three regions of the body Aberrant drug-related behavior History of misuse, abuse, addiction, diversion, dependency, tolerance, and hyperalgesia History of alcoholism Major psychological disorders Age younger than 45 years HIV-related pain High levels of pain exacerbation and low levels of coping strategies Unwilling to participate in multimodal therapy; not functioning close to a near normal lifestyle Source: [97]
Table 9
• E xercise caution with rotation: Conversion tables and equal analgesic tables should not be used to determine opioid starting doses. Assume everyone is opioid naïve, start on a low dose, and titrate slowly to the maximum dose one can safely prescribe.
DEVELOPING A SAFE OPIOID TREATMENT PLAN FOR MANAGING CHRONIC PAIN
As discussed, healthcare professionals should know best clinical practices in opioid prescribing, includ- ing the associated risks of opioids, approaches to the assessment of pain and function, and pain manage- ment modalities. Pharmacologic and nonpharmaco- logic approaches should be used on the basis of cur- rent knowledge in the evidence base or best clinical
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MDMS1526
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