__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
Tapentadol is FDA-approved for treating neuropathic pain associated with diabetic peripheral neuropathy, although it is also used for musculoskeletal pain. During treatment, tapentadol reduced pain intensity more than placebo. PROBLEMATIC OPIOID USE Although evidence for the long-term effectiveness of opioids for chronic pain is weak, evidence for opioid-related harm is abundant and strong. In 2023, nearly 8.6 million Americans 12 years and older reported misusing prescription opioids in the past year [34]. It is important to recognize and differentiate problematic use from adverse side effects of opioids. For instance, tolerance and opioid withdrawal occur with long- term use of prescribed opioids. Clinicians should be able to differentiate this from problematic use. Among adults without a prescription, 41% obtained prescription opioids from friends or relatives for their most recent episodes of misuse [36]. For prescription opioids, long- term therapy is associated with an increased risk of accidental overdose and death. Combining opioids with sedating drugs such as benzodiazepines or alcohol increases the risk of respiratory depression and overdose death. Benzodiazepines have been linked with overdose fatalities in 50 to 80% of heroin overdoses and 40 to 80% in methadone-related deaths [37]. Patients prescribed benzodiazepines who are being initiated on opioids should have their benzodiazepine tapered and discontinued whenever possible. For patients being co-managed by mental health professionals, coordinate a plan regarding continuing or tapering benzodiazepines in the setting of opioid co-prescribing. OTHER ADVERSE EVENTS In addition to risks of misuse, addiction, respiratory depression, and overdose death, there are many well-known side effects associated with chronic opioid use that can significantly compromise quality of life, including constipation, nausea or vomiting, sedation, pruritus, erectile dysfunction, menstrual changes, fracture, immunosuppression, hallucinations, and bhyperalgesia. GASTROINTESTINAL SIDE EFFECTS Constipation is one of the most common opioid-related adverse events, affecting most patients to at least some degree, and usually does not resolve with continued exposure. To mitigate this side effect, patients should use a mild stimulant
laxative such as senna or bisacodyl and increase the dosage in 48 hours if no bowel movement occurs. Physicians should perform a rectal examination if no bowel movement occurs in 72 hours. If there is no impaction, consider other therapies such as an enema, suppository, or magnesium citrate. Medications for refractory, opioid-induced constipation include naloxone derivatives: naloxegol (Movantik), methylnaltrexone (Relistor), or naldemedine (Symproic). Naloxegol is an oral tablet that is used daily while methylnaltrexone is a subcutaneous injection or oral tablet used daily. For nausea or vomiting, physicians should consider a prophylactic antiemetic, add or increase nonopioid pain control agents (e.g., acetaminophen as an opioid-sparing drug), and decrease opioid dose by 25% if analgesic is satisfactory. SEDATION Sedation is the first warning sign of a patient being at risk for opioid overdose. If a patient complains of sedation, determine whether sedation is related to the opioid, eliminate nonessential depressants (such as benzodiazepines or alcohol), reduce dose by 10% to 15% if analgesia is satisfactory, and add or increase nonopioid or nonsedating adjuvant for additional pain to reduce opioid dose. Patients should also be co-prescribed naloxone for opioid overdose reversal. TAMPER-RESISTANT/ABUSE-DETERRENT OPIOIDS One strategy to mitigate the risk of opioid abuse has been the development of “abuse-deterrent” formulations of opioids that make it more difficult to alter for non-oral consumption (e.g., injecting, snorting, or smoking). However, these opioids are more aptly named as “tamper-resistant” formulations instead of “abuse-deterrent” since they are no less potentially addictive than regular opioids when taken by mouth. Tamper- resistant formulations often contain a higher opioid dose than immediate-release preparations. PATIENT EDUCATION An important consideration in framing treatment, and a key message to communicate to patients, is that the goal is not “zero pain” but rather a level of analgesia that maximizes a patient’s physical and mental functioning [38]. A multimodal approach, using both drug and nondrug treatments, should be encouraged.
BEHAVIORS INDICATIVE OF OPIOID MISUSE
Behavior
Frequency in Patients with Opioid Misuse
Requested early refills Increased dose on own
47% 39% 35% 26% 18%
Felt intoxicated from pain medication
Purposely oversedated oneself
Used opioids for purpose other than pain
Source: [35]
Table 2
9
MDUT1125
Powered by FlippingBook