Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition _ ________________
Raising goals after a patient has “succeeded” in achieving them is far more motivational and encouraging than lowering goals after a patient has “failed.” The responsibility for obtaining evidence of success in meeting a functional goal lies with the patient and should be made explicit in the prescribing agreement. If a patient is unable to document or achieve the progress outlined in a treatment plan, this may suggest a need for goal readjustment. INITIATING THERAPY When initiating a trial of opioids, start with immediate-release formulations because their shorter half-life reduces the risk of inadvertent overdose. Prescribe low doses on an intermittent, as-needed basis. For elderly patients who have comorbidities, start at an even lower dose (25 to 50% of usual adult dose). Long-term opioid use often begins with treatment for acute pain, and research shows that opioids are often overprescribed for acute pain. For example, a study of 1,416 patients in a 6-month period found that surgeons prescribed a mean of 24 pills (standardized to 5 mg oxycodone), but patients reported using a mean of only 8.1 pills (utilization rate 34%) [58]. For acute pain, only enough opioids should be prescribed to address the expected duration and severity of pain from an injury or procedure (or to cover pain relief until a follow-up appointment). Several guidelines about opioid prescribing for acute pain from emergency department [59]. and other setting [60]. have recommended prescribing 3 days or less of opioids in most cases. CDC guidelines suggest that for most painful conditions (barring major surgery or trauma) a 3-day supply should be enough, although many factors must be taken into account (for example, some patients might live so far away from a healthcare facility or pharmacy that somewhat larger supplies might be justified) and clinician judgment is important. MONITORING OPIOID USE Follow-up appointments should occur one to four weeks after initiation of opioids or with dose changes; maintenance therapy visits should occur at least every 3 months. Each visit should include an assessment using a pain and function tool, questions about side effects, evaluation of overdose risk, and discussions about how the medication is being used. Many strategies to monitor opioid use and ensure patient safety have been recommended. However, simply asking patients how they are using the medication, how often they take it, how many pills they take at one time, and what triggers them to take the medication can identify patients who may be misusing opioids or need changes to their pain management plan. Other ways to objectively monitor opioid use are checking prescription drug monitoring programs, completing urine drug tests/oral fluid tests, or random pill counts. Relatively infrequent urine monitoring may be appropriate for low-risk patients on a stable dose of opioids (i.e., 1-2 times a year). More frequent or intense monitoring is appropriate for patients during the initiation of therapy or if the dose, formulation, or opioid medication is changed.
In the context of family practice settings (and even pain specialist settings) unobserved urine collection is usually an acceptable procedure for drug testing. Prescribers, however, should be aware of the many ways in which urine specimens can be adulterated. Specimens should be shaken to determine if soap products have been added, for example. The urine color should be noted on any documentation that accompanies the specimen for evaluation, since unusually colored urine could indicate adulteration. Urine temperature and pH should be measured immediately after collection when possible [59]. Prescribers should be familiar with the metabolites associated with each opioid that may be detected in urine, since the appearance of a metabolite can be misleading. A patient prescribed codeine, for example, may test positive for morphine because morphine is a metabolite of codeine. Similar misunderstandings may occur for patients prescribed hydrocodone who appear positive for hydromorphone or oxycodone and oxymorphone. OPIOID ROTATION AND EQUIANALGESIC DOSING “Opioid rotation” means switching from one opioid to another in order to better balance analgesia and side effects. Rotation may be needed because of a lack of efficacy (often related to tolerance), bothersome or unacceptable side effects, increased dosing that exceeds the recommended limits of the current opioid (e.g., dose limitations of co-compounded acetaminophen), or inability to absorb the medication in its present form (i.e., if there is a change in the patient’s ability to swallow, switch to a formulation that can be absorbed by a different route such as transdermal.) Because of the large number of variables involved in how any given opioid will affect any given patient, opioid rotation must be approached cautiously, particularly when converting from an immediate-release formulation to an ER/LA product. As noted previously, equianalgesic charts must be used carefully, and titration must be done carefully and with appropriate monitoring. In some cases, because of the risk of potential harm during the time of rotating from one chronic opioid regimen to another, it may be wise to initially use lower doses of an ER/LA opioid than might be suggested by equianalgesic charts, while temporarily liberalizing, as needed, the use of a short-acting opioid. This would then be followed by gradual titration of the LA opioid to the point where the as-needed short-acting opioid is incrementally reduced until no longer necessary. RECOGNIZING PATIENTS WITH OPIOID USE DISORDER Some patient characteristics are predictive of a potential for drug abuse, misuse, or other aberrant behaviors. The factor that appears to most strongly predict this is a personal or family history of alcohol or drug abuse.
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MDUT1125
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