__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use mately enhance the clinical encounter. In any case in which information regarding treatment options and medication/treatment measures are being provided, the use of an interpreter should be considered. Print materials are also available in many languages, and these should be offered whenever necessary. • Analgesia • Activities of daily living • Adverse or side effects • Aberrant drug-related behaviors • Affect (i.e., patient mood)
INITIATING A TRIAL OF OPIOID THERAPY
The American Society of Interventional Pain Physicians recommends monitoring for side effects (e.g., constipation) and managing them appropriately, including discontinuation of opioids when indicated. (https://painphysicianjournal.com/current/ pdf?article=NDIwMg%3D%3D&journal=103. Last accessed August 15, 2023.) Level of Evidence : I (Evidence obtained from multiple relevant high quality randomized controlled trials for effectiveness) Assessment During Ongoing Opioid Therapy Signs and symptoms that, if present, may suggest a problematic response to the opioid and interference with the goal of functional improvement include [123]: • Excessive sleeping or days and nights turned around • Diminished appetite • Inability to concentrate or short attention span • 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 opi- oid therapy is based on progress toward treatment objectives and absence of adverse effects and risks of overdose or diversion [113]. 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.
Opioid therapy should be presented as a trial for a pre-defined period (usually no more than 30 days). The goals of treatment should be reason- able improvements in pain, function, depression, anxiety, and avoidance of unnecessary or excessive medication use [113]. The treatment plan should describe therapy selection, measures of progress, and other diagnostic evaluations, consultations, referrals, and therapies. In opioid-naïve patients, start at the lowest possible dose and titrate to effect. Dosages for opioid-tolerant patients should always be individualized and titrated by efficacy and tolerability [113]. The need for fre- quent progress and benefit/risk assessments during the trial should be included in patient education. Patients should also have full knowledge of the warn- ing signs and symptoms of respiratory depression. Prescribers should be knowledgeable of federal and state opioid prescribing regulations. Issues of equianalgesic dosing, close patient monitoring during all dose changes, and cross-tolerance with opioid conversion should be considered. If neces- sary, treatment may be augmented, with preference for nonopioid and immediate-release opioids over ER/LA opioids. Taper opioid dose when no longer needed [114]. 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 [113]. This can include input from family members and/or the state prescription drug monitoring program (PDMP) [113]. 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 [10]:
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MDMS1526
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