Responsible and Effective Opioid Prescribing _ ____________________________________________________
degree than other opioids. As a result, oxycodone should not be considered first-line and should be used only in patients who cannot tolerate other opioids and who have been evaluated for and found not to demonstrate increased risk of abuse. 12. Patients presenting for chronic pain treatment should have a thorough evaluation, which may include the following: a. Medical history and physical examination targeted to the pain condition. b. Nature and intensity of the pain. c. Current and past treatments, with response to each treatment. d. Underlying or co-existing diseases or conditions, including those which could complicate treatment (i.e., renal disease, sleep apnea, chronic obstructive pulmonary disease (COPD), etc.). e. Effect of pain on physical and psychological functioning. f. Personal and family history of substance abuse. g. History of psychiatric disorders associated with opioid abuse (bipolar, attention deficit disorders (ADD/ADHD), sociopathic, borderline, untreated/severe depression). h. Medical indication(s) for use of opioids. 13. Initiation of opioids for chronic pain should be considered on a trial basis. Prior to starting opioids, objective symptomatic and functional goals should be established with the patient. If after a reasonable trial these goals are not met, then opioids should be weaned or discontinued. 14. Practitioners should always consider the risk-benefit ratio when deciding whether to start or continue opioids. Risks and benefits should be discussed with patients prior to initiating chronic opioid therapy, and continue to be reassessed during that therapy. If evidence of increased risk develops, weaning or discontinuation of opioids should be considered. If evidence emerges that indicates that the opioids put a patient at the risk of imminent danger (overdose, addiction, etc.), or that they are being diverted, opioids should be discontinued and the patient should be treated for withdrawal, if needed. a. Exceptions to this include patients with unstable angina and pregnant patients, especially in the 3rd trimester (withdrawal could precipitate pre-term labor). b. Components of ongoing assessment of risk include: i. Review of the Prescription Drug Monitoring Program (PDMP) information. ii. Periodic urine drug testing (including chromatography) – at least yearly in low risk cases, more frequently with evidence of increased risk. iii. Violations of the opioid agreement. iv. Periodic pill counts may also be considered for high-risk patients. 15. All patients on chronic opioid therapy should have informed consent consisting of: a. Specifically detailing significant possible adverse effects of opioids, including (but not limited to) addiction, overdose, and death. It is also recommended practitioners discuss with patients the effect opioid use may have on the ability to safely operate machinery or a vehicle in any mode of transportation. b. Treatment agreement, documenting the behaviors required of the patient by the prescribing practitioner to ensure that they are remaining safe from these adverse effects. 16. Initial dose titration for both acute and chronic pain should be with short-acting opioids. For chronic therapy, it would be appropri- ate once an effective dose is established to consider long-acting agents for a majority of the daily dose. 17. Opioids should be prescribed in the lowest effective dose. This includes prescribing the lowest effective dose for the shortest possible duration for post-operative care and acutely-injured patients. If daily doses for chronic pain reach 50 morphine milligram equiva- lents (MMEs), additional precautions should be implemented (see #14.b. above). Given that there is no evidence base to support efficacy of doses over 90 MMEs, with dramatically increased risks, dosing above this level is strongly discouraged, and appropriate documentation to support such dosing should be present on the chart. 18. The use of methadone is not encouraged unless the practitioner has extensive training or experience in its use. Individual responses to methadone vary widely; a given dose may have no effect on one patient while causing overdose in another. Metabolism also varies widely and is highly sensitive to multiple drug interactions, which can cause accumulation in the body and overdose. For a given analgesic effect, the respiratory depressant effect is much stronger compared to other opioids. Finally, methadone can have a potent effect on prolonging the QTc, predisposing susceptible patients to potentially fatal arrhythmias.
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MDWI1625
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