__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
judgement if opioids are deemed necessary. If opioid treatment is necessary, it is suggested that the dose be limited and only long enough to complete an adequate evaluation and to seek consultation, as needed. Recommendation 6.3: Begin with Immediate Release/ Short-Acting (IR/SA) The trial should begin with immediate-release/short-acting (IR/SA) opioid medication. Immediate-release, short-acting (IR/SA) opioid medications are generally safer and easier to titrate to an effective dose. CDC experts agreed that for patients not already receiving opioids, prescribers. Utah Clinical Guidelines on Prescribing Opioids for the Treatment of Pain should not initiate opioid treatment with extended-release/long-acting opioids (ER/LA) and should not prescribe ER/LA opioids for intermittent use. ER/LA opioids should be reserved for severe continuous pain and should be considered only for patients who have received IR/SA opioids daily for at least one week. Initial treatment should not use methadone, fentanyl, or the combination of opioids and benzodiazepines. Recommendation 6.4: Prescribe the Lowest Effective Dose When opioids are prescribed for the treatment of chronic pain, prescribers should prescribe the lowest effective dose. Prescribers should use caution when prescribing opioids at any dosage, should carefully re-assess evidence of individual benefits and risks when increasing dosage to >50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to >90 or carefully justify a decision to titrate dosage to >90 MME/day. The CDC states that although there is not a single dosage threshold below which overdose risk is eliminated, holding dosages below 50 MME/day would likely reduce risk among most patients who would experience fatal overdose at higher prescribed dosages. Utilization of any dose should be based on incremental functional gains. Benefits of high-dose opioids for chronic pain are not established. At the same time, risks for serious harm increase at higher opioid doses. Opioid overdose risk increases in a dose-response manner. Dosages of 50-100 MME/day increase risks for opioid overdose by 1.9-4.6 times and dosages >100 MME increase risk by 2.0-8.9 times as compared with the risk at 1-20 MME/da [4]. Recommendation 6.5: Prevent Prescription Fraud The prescription for opioid therapy should be written on tamper-resistant prescription paper or e-prescribed to prevent prescription fraud.
To reduce the chance of tampering with the prescription, write legibly and keep a copy in your records. According to the Drug Enforcement Administration (DEA), all records related to controlled substances must be maintained and be available for inspection for a minimum of two years. Recommendation 6.6: Implement Dose Titration and Re- evaluation Regular face-to-face visits with the patient and evaluation of progress against goals should be scheduled during the period when the opioid dosage is being adjusted. The opioid trial or long-term treatment should be continually evaluated for functional benefit and achievement of treatment goals, using appropriate tracking tools. Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function. Monitoring progress toward patient-centered functional goals (e.g., walking the dog or walking around the block, returning to part-time work, attending family sports or recreational activities) can also contribute to the assessment of functional improvement. Prescribing providers should use these goals in assessing the benefits of opioid therapy for individual patients and in weighing benefits against risks of continued opioid therapy [5]. There are a variety of tracking tools that can be used to set and monitor treatment goals: • Pain Assessment and Documentation Tool (PADTTM) • Brief Pain Inventory (BPI©) • Treatment agreement • Patient Health Questionnaire (PHQ-4 or PHQ-9) These forms can be found in the Tools and Resources section. Recommendation 6.7: Avoid Parenteral Opioids Parenteral (intravenous, intramuscular, or subcutaneous) administration of opioids for chronic pain is strongly discouraged, unless prescribing within an inpatient or palliative care setting. Any circumstance warranting parenteral administration should be clearly justified by clinical exigencies (e.g., bowel obstruction, terminal care, etc.). These guidelines do not consider intrathecal administration and this recommendation was not intended to discourage trained and qualified physicians from using intrathecal opioid medications when indicated. Daily intramuscular (IM) or subcutaneous (SC) injections should be avoided except in a highly supervised environment, such as during an admission to the hospital or hospice.
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