Older adults People who are ≥65 years require cautious opioid dosing and management as they may have numerous co-occurring medical problems with treatments that increase the risk for polypharmacy and harmful drug interactions. 78 Their risk for falls and cognitive effects with sedating medications and their sensitivity to analgesic effects are increased. In addition, prescription drug or other substance use may be difficult to spot, mimicking symptoms of common conditions such as dementia, diabetes, and depression. Initial doses should be 25-50% lower than in those who are younger. 86 The VA/DoD practice guideline suggests that tramadol has benefits in older patients because of its partial mu agonist activity and demonstrated safety profile when combined with ACET, though drug-drug interactions should be evaluated when prescribing tramadol. 23 Children and adolescents Evaluating the origin of the pain condition is important in the pediatric age group. If pain is not controlled, children are at risk for persistent pain as they grow to adulthood. 3 Use of multidisciplinary treatments is advised as is treatment of psychological conditions to manage difficulty coping, anxiety, and depression. It has been suggested that opioid analgesia may be indicated for certain chronic pediatric conditions; however, current guidelines generally exclude this population from treatment recommendations, and scientific investigation is scant into the indications and safety concerns with opioids for the pediatric population. 87 Accidental exposure to and ingestion of opioids can result in death. People with renal and hepatic impairment Extra caution and increased monitoring is necessary when initiating and titrating opioid doses in people with renal and hepatic impairment. 64 In patients with renal compromise, accumulation resulting in toxicity has been observed in case studies; therefore, it is advised to monitor for opioid toxicity and to use non- opioids when possible. 88 People with sickle cell disease Sickle cell disease affects approximately 100,000 people in the United States and is characterized by complex acute and chronic pain symptoms. 1 The disease is particularly prevalent among African Americans. According to the HHS Inter-Agency Task Force on best pain management practices, unpredictable, episodic exacerbations of acute pain pose a challenge to patients with sickle cell disease, and this pain generally has not responded to non- opioids prior to presentation. 3 Limited access to oral opioids at home for the treatment of unplanned acute pain can result in increased use of healthcare services that could have been avoided. Stigma, negative practitioner attitudes, and perceived racial bias may further complicate care. Effective models of pain treatment for patients with sickle cell disease include multidisciplinary teams of practitioners with experience treating the disease.
An estimated 32,128 babies were born with NOWS in 2016. 83 Babies born to women who are taking opioids are at risk for birth defects (including neural tube defects, congenital heart defects, and gastroschisis), preterm delivery, poor fetal growth, and stillbirth. 64 Given the risks during pregnancy and postpartum, HCPs are encouraged to include obstetricians and gynecologists as part of the pain care management team. 3 When caring for pregnant women who are prescribed opioids, HCPs should arrange for delivery at a facility prepared to evaluate and treat NOWS. 64 Women with SUD should be offered evidence-based treatment. In pregnant women with OUD, the risk of opioid exposure from opioids used to treat OUD should be discussed and balanced against the risk of untreated OUD, which might lead to illicit opioid use associated with outcomes such as low birth weight, preterm birth, or fetal death. 84 Pain management guidelines in Tennessee recommend the following measures when treating women of child-bearing age: 85 Initiating therapy 1. The provider should discuss a method to prevent unintended pregnancy with every woman of child- bearing age who has reproductive capacity before opioids are initiated. 2. The practitioner should obtain a signature indicating that any woman who wishes to become or is at risk to become pregnant has been educated about the risks and benefits of opioid treatment during her pregnancy. 3. Women of child-bearing age who have reproductive capacity shall undergo a pregnancy test prior to the initiation of opioids. 4. Women of child-bearing age who have reproductive capacity should be asked about the possibility of pregnancy at each visit. For women who wish to avoid unintended pregnancy, use of long-acting reversible contraceptives should be discussed, or referral to appropriate high-risk obstetrician made. Ongoing therapy 1. The provider should discuss a method to prevent unintended pregnancy with every woman of childbearing age who has reproductive capacity when opioids are initiated. 2. The provider shall advise every woman of child- bearing potential on opioids that she be on a method to prevent unintended pregnancy specifically considering long acting contraceptive methods. 3. The treatment agreement shall include an expectation that a female patient will tell the provider if she becomes pregnant or plans to become pregnant. 4. If she plans to become or becomes pregnant she shall be referred to an obstetrician. 5. When a UDT is performed, results must be documented in the medical record.
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Book Code: MDCO1025
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