__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
coordinated care of both the chronic pain and psychiatric conditions. Because psychological distress frequently interferes with improvement of pain and function in patients with chronic pain, use validated instruments such as the Generalized Anxiety Disorder (GAD)-7 and the Patient Health Questionnaire (PHQ)-9 or the PHQ-4 to assess for anxiety, post-traumatic stress disorder, and/or depression (205) [12]. Opioid therapy should not be initiated during acute psychiatric instability or uncontrolled suicide risk, and prescribers should consult a behavioral health specialist for any patient with a history of suicide attempt or psychiatric disorder. In addition, patients with anxiety disorders and other mental health conditions are more likely to receive benzodiazepines, which can exacerbate opioid-induced respiratory depression and increase the risk for overdose. For treatment of chronic pain in patients with depression, prescribers should strongly consider using tricyclic or SNRI antidepressants for analgesic as well as antidepressant effects [13].
When tapering a patient from opioid treatment, the rate of taper will depend on their medical, social, and mental health factors. Medicine should be dispensed in small increments, no more than a weekly supply. Strategies for Tapering and Weaning can be found in the Tools and Resources section. For prescribers who are not familiar with opioid tapering within the context of pain care (i.e., no opioid use disorder co-morbidity), consultation with a pain medicine specialist is recommended. If opioid use disorder is suspected, consultation with a SUD specialist is recommended. When patients receiving both benzodiazepines and opioids require tapering to reduce risk for fatal respiratory depression, it might be safer and more practical to taper opioids first (see Recommendation 7). The reason for this is because there is a greater risk of benzodiazepine withdrawal relative to opioid withdrawal and tapering opioids can be associated with anxiety. Prescribers should taper benzodiazepines gradually, because if discontinued abruptly this may cause withdrawal with rebound anxiety, hallucinations, seizures, delirium tremens, and, in rare cases, death. A commonly used benzodiazepine tapering schedule that has been used safely and with moderate success is a reduction of the benzodiazepine dose by 25% every 1–2 weeks [14].. Chronic Pain Recommendation 11: Methadone Recommendation 11.1: Avoid Methadone Unless Trained Methadone should not be used for pain unless the prescriber has extensive training or experience in its use and when the benefits outweigh the known risks. Methadone has highly complex and variable pharmacokinetics and pharmacodynamics, making it unsuitable as a preferred (1st or 2nd line) extending-release/long-acting (ER/LA) opioid analgesic for the management of chronic pain when around- the-clock opioids are indicated. Its use for this indication has been associated with a disproportionately high incidence of prescription opioid-related deaths. Methadone is one option for maintenance therapy for patients who are addicted to opioids, who have been transitioned from their other opioid medications, and who are under a frequent urine drug screening plan. The DEA requires special registration as a Narcotic Treatment Program (NTP) for prescribers to use methadone for this purpose. Buprenorphine is another option for long-term therapy of opioid use disorder. An ECG screening should be performed on patients who will be receiving methadone. Caution: Anti-depressants may prolong the QT interval and increase the risk of cardiac death when taken with methadone.
CHRONIC PAIN RECOMMENDATION 10: DISCONTINUING OPIOID TREATMENT Recommendation 10.1: Discontinue Treatment
Opioid treatment should be discontinued when pain problems have been resolved, treatment goals are not being met, adverse effects outweigh benefits, or dangerous or illegal behaviors are demonstrated. Dangerous or illegal behaviors may include frequent requests for refills prior to the expected use date, positive urine drug screens for non-prescribed medications, negative urine drug screens for opiates that have been prescribed and the patient states they are taking, and suspicion of diverting medications to others. The decision to discontinue opioid treatment should ideally be made jointly with the patient and the family/caregivers when appropriate (Federation of State Medical Boards, 2004). This decision requires careful consideration of the treatment outcomes and the need to provide ongoing monitoring. When the patient is discharged, the prescriber is obliged to offer continued monitoring for 30 days post-discharge. Once a provider-patient relationship is established, the prescriber owes a continuing duty to provide care until that relationship is appropriately terminated. Prescribers should adhere to the standard of care for their specific discipline when dismissing a patient. The failure to do so may constitute neglect or abandonment. Recommendation 10.2: Safely Taper and Refer to Treatment When a patient chooses to stop treatment or has been discharged for treatment plan violations, offer assistance to safely taper medications or obtain appropriate treatment.
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