Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition _ ________________
MITIGATING RISKS (7.1-7.7) CHRONIC PAIN RECOMMENDATION 7: RISK MITIGATION Recommendation 7.1: Avoid and Counsel Against Combining Opioids with CNS Depressants Avoid prescribing, and counsel against, concurrent use of opioids and benzodiazepines. Patients should also be counseled against concurrent use of opioids with other sedating substances, including alcohol muscle relaxant drugs, and sedative hypnotics including prescription and over-the- counter sleep aids, etc. Concurrent use of alcohol, benzodiazepines, and other CNS depressants increases the risk of respiratory depression, which can potentially cause death. Concurrent use of benzodiazepines requires explicit medical justification due to the serious risk of respiratory depression. For putative psychiatric indications, psychiatric consultation should be sought to treat the patient’s condition with potentially less toxic drug-to-drug interactions. Prescribers should warn patients of the high-risk interaction. Recommendation 7.2: Evaluate Risks Associated with Sleep Apnea Prescribers should assess the patient’s risk for sleep apnea and strongly consider formal screening. Risk factors for sleep-disordered breathing include congestive heart failure and obesity. Experts noted that careful monitoring and cautious dose titration should be used if opioids are prescribed for patients with mild sleep-disordered breathing. Prescribers should avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing whenever possible to minimize the risk of opioid overdos [6]. Naloxone rescue medication should be provided to the family/ caregivers, as well as education on when to administer naloxone if the patient has risk of sleep apnea, regardless of total daily dose of MME used. Educating the family/caregivers about the signs of an opioid overdose may help detect problems before they lead to a serious complication. Patients and family/caregivers should learn to recognize the danger signs of respiratory depression and know to how to offer help and summon medical help immediately if a person demonstrates any of the following signs while on opioids: • Episodic cessation of breathing. • Periods of irregular or other sleep-disordered breathing. • Extreme drowsiness and difficulty being awakened. • Slow, shallow breathing with little chest movement. • Increased or decreased heartbeat or palpitations. • Feeling faint, dizzy, or confused.
Recommendation 7.3: Obtain Urine Drug Screens Prescribers should perform drug screening on randomly selected visits and any time aberrant behavior is suspected. A good practice is to give all patients taking chronic controlled substance prescriptions at least an annual urine tests and high-risk patients more frequent random urine tests with no advance notice. Drug testing has been shown to identify the presence of illegal drugs, unreported prescribed medication, unreported alcohol use, or the absence of the patient’s prescribed medication. This assists the prescriber in determining whether the opioid therapy is appropriate and in determining the required frequency of monitoring. It also provides an opportunity to discuss the risks of opioid treatment. Random pill counts may also be useful. Immunoassays can be done in the office. These screening tests determine if opioids are present but do not identify specific ones, which can subsequently be determined by confirmatory laboratory testing. However, in many cases, confirmation testing can be eliminated by carefully going over the results of the initial in-office test with the patient. Prescribers need to recognize that immunoassays have both false positive and false negative results. Over-the-counter medication, for example, can cause a positive result. Many synthetic opioids are not detected by urine immunoassay screening and require confirmation testing if suspected. The prescriber may want to consider confirmatory testing or consultation with a Certified Medical Review Officer if drug test results are unclear. An abnormal drug screen should be specified in the treatment plan as a possible reason to cease treatment. Recommendation 7.4: Check the Utah Controlled Substance Database (CSD) During treatment of chronic pain with opioid medications, the CSD should be checked at least quarterly. Prescribers should review the patient’s history of controlled substance prescriptions to determine whether the patient is receiving opioid dosages or dangerous combinations that put them at high risk for overdose. Prescribers should communicate with others managing the patient or prescribing controlled substances to coordinate care and to improve patient’s safety. Aberrant findings in the CSD (or from urine drug screening) necessitate a frank conversation with the patient. Such findings, based upon the treatment plan, may be cause for tapering/discontinuing controlled substances, referring the patient to a pain management specialist, or developing a new treatment plan. Recommendation 7.5: Co-prescribe Naloxone As an intervention to prevent a potential opioid overdose death, co-prescribe an approved naloxone delivery kit for patients receiving opioids for treatment of chronic pain. Prescribers should mitigate the risk of an opioid overdose by offering patients naloxone when increased opioid overdose risk factors are present, such as a history of overdose or substance
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