Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________ full opioid agonists given concurrently. This can result in several types of adverse outcomes [15]: • Inadequate analgesia from blocking the effect of concurrent opioids • Opioid overdose when buprenorphine plasma level declines in the presence of high-dose concurrent opioids
CASE STUDY An unemployed man, 64 years of age, is brought to an emergency department by ambulance, after his wife returned from work to find him lying on the couch, difficult to arouse and incoherent. He has a past history of hypertension, diabetes (non-insulin dependent), mild chronic obstructive pulmonary disease, and chronic back and shoulder pain, for which he has been prescribed hydrocodone/acet- aminophen for many years. His wife reports that while he seemed his usual self when she left for work that morning, he had, in recent weeks, been more withdrawn socially, less active, and complained of greater discomfort from the back and shoulder pain. She knows little about his actual medication usage and expresses concern that he may have been taking more than the prescribed amount of “pain medicine.” On evaluation, the patient is somnolent and arouses to stimulation but is non-communicative and unable to follow commands. His blood pressure is normal, he is afebrile, and there are no focal neurologic defi- cits. Oxygen saturation, serum glucose, and routine laboratory studies (blood counts and metabolic pro- file) are normal except for mild elevation in blood urea nitrogen (BUN) and creatinine; the urine drug screen is negative except for opioids. Additional his- tory from the family indicates that the patient has been admitted to other hospitals twice in the past three years with a similar presentation and recovered rapidly each time “without anything being found.” Following admission, the patient remains stable- to-improved over the next 12 to 18 hours. By the following day, he is awake and conversant and looks comfortable. On direct questioning, he reports recent symptoms of depression but no suicidal ideation. The patient describes an increased preoc- cupation with his pain syndrome, difficulty sleeping at night, and little physical activity during the day, in part because of physical discomfort. He is vague about his medication regimen and admits to taking “occasional” extra doses of hydrocodone for pain relief.
• Acute opioid withdrawal syndrome as the buprenorphine plasma level declines in the presence of inadequate additional opioids • Acute opioid withdrawal syndrome when buprenorphine is administered to patients receiving long-term opioid analgesic therapy Buprenorphine has an analgesic duration of 4 to 8 hours and a 24- to 48-hour suppression of opioid withdrawal and craving. As a partial agonist, the analgesic effect has a ceiling after which dose escala- tion does not lead to improved pain control. Thus, patients receiving buprenorphine for opioid use disorder must discontinue this medication if they require full-agonist opioid analgesics for chronic pain control. Before taking this step, the clinician and patient should weigh the risks and benefits, including the risks of prescription opioid abuse and potential relapse to drug use without buprenor- phine, and the potential improvements in pain and function that may come with full-agonist opioid analgesic therapy [20]. Patients in recovery from opioid or other substance use disorders may have specific preferences for types of analgesic medications and may have greater awareness of their risk of relapse if given opioids for their chronic pain. Studies of patients with pain in recovery from substance use disorders have found that while some do relapse when receiving long- term opioid analgesic therapy, untreated pain can itself be a trigger for relapse. A prescription opioid agreement may help provide a sense of control that recovering addicts often fear losing when taking opioid analgesics [20].
50
MDMS1526
Powered by FlippingBook