__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
CAUTION WITH DOSE ESCALATION When escalating opioid doses, be aware of two possible critical daily thresholds — 50 and 90 MMED. According to the CDC, doses >50 MMED are associated with more than double the risk of overdose compared to patients on <50 MMED. For patients on >90 MMED, a 9-fold increase in mortality risk was observed compared with the lowest opioid doses. Use of 90 MMED is considered by several guidelines as a “red flag” dose beyond which careful assessment, more frequent monitoring, and documentation of expected benefits are required (note, however, that this limit doesn’t apply to patients with severe cancer pain or end-of-life pain). The total MMED for all prescribed opioids should be used (MMED is automatically calculated on many state PDMP reports). Physician clinical judgment is also important in determining daily thresholds, and the CDC limits can be used as a guide. ROLE OF ER/LA OPIOIDS AND METHADONE ER/LA opioids include methadone, transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine. As noted previously, continuous, time-scheduled use of ER/LA opioids is not more effective or safer than intermittent use of immediate-release opioids, and ER/ LA opioids increase risks for opioid misuse or addiction. The 2022 CDC guidelines suggest that ER/LA opioids should be reserved for severe, continuous pain and should be considered only for patients who have received immediate- release opioids daily for at least 1 week. Additional caution is required when prescribing ER/LA opioids in older adults or patients with renal or hepatic dysfunction because decreased clearance of drugs among these patients can lead to accumulation of drugs to toxic levels and persistence in the body for longer durations. When an ER/LA opioid is prescribed in the primary care setting, using an agent with predictable pharmacokinetics and pharmacodynamics is preferred to minimize unintentional overdose risk (i.e., the unusual characteristics of methadone and transdermal fentanyl make safe prescribing of these medications for pain more challenging). The use of methadone for chronic pain in primary care should generally be avoided because of higher methadone-related risks for QTc prolongation and fatal arrhythmias. Equianalgesic dose ratios are highly variable with methadone, making conversion from other opioids difficult, with attendant increased risk of overdose. If methadone or transdermal fentanyl is considered, refer patients to pain management specialists with expertise in using this medication.
Signs of physical dependence include the appearance of an abstinence syndrome with abrupt cessation or diminution of chronic drug administration, which is not the same as OUD, a condition where patients lose control of their opioid use or compulsively use opioids. The nature and time of onset of this syndrome vary with drug actions and half-life. Slow tapering of the drug (e.g., 10-15% reduction in dosage per day or every other day) usually avoids the appearance of an abstinence syndrome. MANAGING NONADHERENT PATIENTS Patients who exhibit aberrant drug-related behaviors or nonadherence to an opioid prescription should be monitored more closely than compliant patients. Concern that a patient is nonadherent should prompt a thorough evaluation. Consultation with an addiction medicine specialist or psychiatrist may be necessary if addiction is suspected or if a patient’s behavior becomes so problematic that it jeopardizes the clinician/patient relationship. TREATMENT TERMINATION Reasons for discontinuing an opioid analgesic can include the healing of or recovery from an injury, medical procedure, or condition; intolerable side effects; lack of response; or discovery of misuse of medications. Regardless of the reason, termination should be accomplished so as to minimize unpleasant withdrawal symptoms by tapering the opioid medication slowly, by carefully changing to a new formulation, or by effectively treating an opioid use disorder if it has developed. Approaches to weaning range from a slow 10% reduction per week to a more aggressive 25% to 50% reduction every few days. In general, a slower taper will produce fewer unpleasant symptoms of withdrawal; however, this may not be the safe course of action for a patient experiencing side effects or who has OUD. Opioid therapy must be discontinued or reevaluated whenever the risk of therapy is deemed to outweigh the benefits being provided. A clinician may choose to continue opioid treatment with intensified monitoring, counseling, and careful documentation if it is deemed in the best interest of the patient. This requires, however, careful consideration and a well-documented risk management plan that addresses the greater resources necessary for opioid continuation following evidence of misuse. If termination of the physician/patient relationship is deemed necessary (though it rarely is), clinicians must ensure that the patient is transferred to the care of another physician or provider and ensure that the patient has adequate medications to avoid unnecessary risk, such as from uncontrolled or unpleasant withdrawal. Practitioners can be held accountable for patient abandonment if medical care is discontinued without justification or adequate provision for subsequent care.
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MDUT1125
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