__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
Many states allow patients, family members, caregivers, and/ or friends to request naloxone from their local pharmacist. Anyone receiving naloxone should be taught how to use the device and about the common signs of overdose (slow or shallow breathing, gasping for air, unusual snoring, pale or bluish skin, not waking up or responding, pinpoint pupils, slow heart rate). A variety of naloxone products are available. The intranasal device with atomizer and intramuscular (IM) shots requires the most manipulation in order to administer. Intranasal naloxone and the auto-IM injector are easier to use but vary greatly in terms of price and insurance coverage. SUCCESSFUL OPIOID TAPERING Patients who do not achieve functional goals on stable or increasing opioid doses or those with unacceptable side effects should have the opioid tapered or discontinued. Patients sometimes resist tapering or discontinuation, fearing increased pain. However, a 2017 systematic review found that dose reduction or discontinuation resulted in reduced pain (eight studies), improved function (five studies), and improved quality of life (three studies), although the evidence was not strong because the analysis included poor-quality studies with uncontrolled designs and the interventions and outcome measures were heterogeneous [63]. Recommendations for tapering schedules vary. One source recommends a 10% decrease weekly based on years of opioid use (i.e., 10% decrease monthly for patients using opioids ≥4 years). For patients on high-dose opioids (i.e., ≥90 MMED), taper 10% until patient is taking 30% of the total initial dose, then recalculate 10% taper based on the new total opioid dose to slow taper [64]. The rate of opioid taper should be adjusted based on patient-specific factors such as the severity of withdrawal symptoms. In 2019 the FDA, recognizing the risks associated with abrupt discontinuation of opioid analgesics, required new labeling for opioid analgesics to guide prescribers about safe tapering practices. The key elements include [65]. • Do not abruptly discontinue opioid analgesics in patients physically dependent on opioids. Counsel patients not to discontinue their opioids without first discussing the need for a gradual tapering regimen. • Abrupt or inappropriately rapid discontinuation of opioids is associated with serious withdrawal symptoms, uncontrolled pain, and suicide. • Ensure ongoing care of the patient and mutually agree on an appropriate tapering schedule and follow-up plan. • In general, taper by an increment of no more than 10-20% every 2-4 weeks. • Pause taper if the patient experiences significantly increased pain or serious withdrawal symptoms.
• Use a multimodal approach to pain management, including mental health support (if needed). • Reassess the patient regularly to manage pain and withdrawal symptoms that emerge and assess for suicidality or mood changes. • Refer patients with complex comorbidities or substance use disorders to a specialist. OPIOID USE DISORDER (OUD) OUD is a problematic pattern of opioid use that causes significant impairment or distress. As with other chronic diseases, OUD usually involves cycles of relapse and remission. DSM-5 diagnosis of OUD is based on clinical evaluation and determination that a patient has problematic opioid use leading to clinically significant impairment or distress involving at least two of the following within a 12-month period: • Opioids taken in larger amounts, or for longer periods, than intended • Persistent desire or unsuccessful attempts to control or reduce use • Significant time lost obtaining, consuming, and recovering from opioids • Craving or a strong desire or urge to use opioids • Failure to complete obligations (i.e., work, home, or school) due to opioids • Persistent or recurrent social or interpersonal problems due to opioids • Giving up enjoyable social, work, or recreational activities due to opioids • Recurrent opioid use in situations in which it is physically hazardous (e.g., driving) • Continued use despite a physical or psychological problem caused by or worsened by opioid use • Tolerance (unless opioids are being taken as prescribed) • Using opioids to prevent withdrawal symptoms (unless opioids are being taken as prescribed) OUD is not a binary diagnosis; rather it exists as a continuum, with DSM-5 describing three levels of severity: • Mild OUD (2-3 criteria) • Moderate OUD (4-5 criteria) • Severe OUD (≥6 criteria) In 2021, an estimated 2.5 million people aged 18 years or older in the United States had opioid use disorder in the past year [66]. OUD can be effectively managed with medication-assisted treatment (MAT), but only an estimated 22% of adults with OUD currently receive such treatment.
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MDUT1125
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