Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________ agencies are noting increases in heroin overdoses, crime, and other public health problems [173]. These unanticipated negative consequences pro- vide a compelling reminder that societal problems of substance abuse and addiction are complex and multifaceted. Simplistic solutions seeking only to restrict drug supply have never succeeded in reduc- ing drug demand. INCREASINGLY RESTRICTED ACCESS of non-serious violations can be managed by patient education and enhanced monitoring [176]. The basis of opioid analgesic termination should be consistent with those for any other medication class, where discontinuation is prompted when opioid therapy benefits are outweighed by harms. Reasons
given for termination include [177]: • Opioids are no longer effective. • Opioids no longer stabilize the patient or improve function. • Patient has lost control over his or her use of the opioid. • Patient is diverting drugs. • Patient is not able to stop using alcohol, benzodiazepines, or other CNS depressants. • Adverse effects become unmanageable. PATIENTS WITH CHRONIC PAIN AND SUBSTANCE USE DISORDER Alcohol, street drugs, and prescription medica- tions are used by patients with chronic pain for diverse reasons, including the self-medication of pain, insomnia, depression or anxiety, or intrusive trauma memories; as recreation with occasional use; as a compulsive act driven by addiction; and to avoid withdrawal symptoms [178]. Chronic pain and substance use disorder often coexist, and each condition is a risk factor for the other. Whenever possible, active substance abuse disorder in patients with chronic pain should be treated because of safety concerns and because active substance use disorder interferes with the therapeutic progress in the pain condition due to overlapping mechanisms. Active addiction augments pain stimuli processing and perception through alterations in the input, process- ing, and modulation of nociceptive stimuli, sympa- thetic activation, hypothalamic-pituitary-adrenal (HPA) axis dysregulation, and opioid tolerance (in active opioid addiction). Persons with addiction have reduced pain tolerance and increased pain perception, the result of baseline perceptual pathway reorganization from the interactive effects of both conditions [20].
TO THERAPIES FOR OPIOID ADDICTION Restricted access to opioid analgesics is also nega- tively impacting patients attempting to access treat- ment for opioid addiction. The opioid analgesics methadone and buprenorphine comprise the backbone of outpatient multidisciplinary treatment of opioid addiction in the United States. A 2013 press release by the ASAM states that investigation into state Medicaid and private insurance coverage found increasing restrictions due to policy changes over coverage, daily dose, prior authorizations, and the requirement of previous failed treatment approaches. The end result of these imposed barri- ers to accessing opioid addiction medications is an increase in patient denial of services, which ASAM states is senseless and unethical considering the epidemic-level rates of opioid addiction and over- dose deaths [174]. PATIENT TERMINATION Several clinical practice guidelines for safe opioid prescribing explicitly endorse patient termination in the event of abnormal UDT results, aberrant drug-related behaviors, other violations of the patient-provider contract, or deterioration in the provider-patient relationship [97]. This approach is controversial, and as stated by Ballantyne, “The surest way to hurt patients (and society) is to aban- don them when they deviate from the constructive relationship envisaged by the treating practitioner, only to trail from physician to physician to obtain the drug they need, or worse still, seek illicit sup- plies” [175]. Clinician response to aberrant behaviors should involve an assessment of seriousness, underlying cause, likelihood of recurrence, and clinical context of the aberrant behavior [115]. Occasional episodes
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MDMS1526
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