__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use. Naloxone administration is intended to reverse life-threatening respiratory depression. Naloxone is commercially available by prescription for emergency use in autoinjector and intranasal administration forms. See Chronic Pain Recommendation 7.6 for the duration of action of naloxone and additional information. On December 8, 2016, the Utah Department of Health issued a standing order that pharmacists may dispense naloxone to concerned family members, caregivers, friends, and patients without a written prescription. However, pharmacies are not required to participate in the standing order. For patient education materials and resources on naloxone, visit https://naloxone.utah.gov/ Recommendation 7.6: Provide Overdose Education and Counseling Provide the patient and family/caregivers information on the signs and symptoms of an opioid overdose, how to obtain naloxone, and the timely and proper administration of naloxone. Patients and family/caregivers should learn to recognize the danger signs of an opioid overdose: • Extremely pale face and/or feels clammy to the touch. • Body goes limp. • Fingernails or lips have a purple or blue color. • Vomiting or making gurgling noises. • Unable to be awakened or unable to speak. • Breathing or heartbeat slows or stops. 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 also learn to recognize the danger signs of respiratory depression (see Recommendation 7.2) and know how to offer help and summon medical help immediately. Counseling about administration of naloxone for suspected overdose should be provided in those cases where naloxone is co-prescribed. Naloxone can be prescribed by a healthcare provider or by a pharmacist, as per the Utah Department of Health standing order. Once naloxone is administered, professional emergency care needs to be provided by calling 911. Naloxone wears off in 30-90 minutes, so naloxone administration may need to be repeated. Meanwhile, CPR or mouth-to-mouth resuscitation may also need to be administered, so family/caregivers should receive training in both when naloxone is prescribed. Warning: The standard IV dosage of naloxone is 0.4 mg and the intranasal dose is 2-4 mg. Administering an excessive amount of naloxone by repeating doses too frequently or using
a high-dose preparation can cause the patient to experience acute opioid withdrawal symptoms which can cause seizures or even be life threatening. See Instructions for Naloxone Administration in the Tools and Resources section. Additional information about naloxone for the public, prescribers, pharmacists, and first responders can be found at naloxone.utah.gov/. Recommendation 7.7: Counsel Patients on Safe Storage, Disposal, and Diversion Patients should be encouraged to securely store their medications, not share with others, and to dispose of opioids properly when the pain has resolved to prevent non-medical use of the medications. For patient education materials and resources on safe storage and disposal, visit www.useonlyasdirected.org. Naloxone may not be effective if opioids are misused in combination with other sedatives or stimulants. It is not effective in treating overdoses of benzodiazepines or stimulant overdoses involving cocaine and amphetamine [5].
TREATMENT MANAGEMENT (8.1-10.2) CHRONIC PAIN RECOMMENDATION 8. MONITORING TREATMENT AND DOSE ADJUSTMENTS Recommendation 8.1: Monitor Opioid Therapy
Once a stable dose has been established, regular monitoring should be conducted at face-to-face visits. During these visits, treatment goals, affect and mood, analgesia, activity and level of function, adverse effects, and aberrant behaviors should be monitored. These assessments can be remembered as the “5 A’s.” 5 A’s Opioid Therapy Monitoring Tool: • Affect: determine if pain has impacted the patient’s mood • Analgesia: inquire about level of pain (current, recent, trends, etc.) • Activity: assess both the patient’s function and overall quality of life • Adverse events: determine whether the patient is having medication side effects • Aberrant behavior: regularly evaluate for possible substance use disorder related behavior Also, it is recommended to assess the patient’s airway and sleep apnea status [6]. Recommendation 8.2: Evaluate Patient Progress Continuation or modification of therapy should depend on the prescriber’s evaluation of progress towards stated treatment goals.
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