Diversion Most people who misuse prescription opioids are given them freely by friends or family members, though some people buy or steal them. 93 About a third of people who misuse opioids get them by prescription from one doctor. 93 Many misused opioids became available in the community because they
were left over from prescriptions for acute pain. 94 It is incumbent on the HCP to remember that, although most people who are prescribed opioids for pain do not misuse them, it is possible that some people who visit a medical facility for pain are instead seeking opioids to divert for misuse or illegal sale.
CREATING PAIN TREATMENT PLANS
All pain management begins with identifying the cause or causes of pain and the biopsychosocial mechanisms that contribute to its severity and associated disability. 3 An effective treatment plan is built out of a full evaluation to establish diagnosis and emphasizes individualized, patient-centered care. When persistent pain pertains to a specific disease condition or patient population, HCPs are advised to seek out evidence-based practice guidelines that are relevant. 3 The patient’s pain type and previous treatments should be evaluated to see if opioid therapy is likely to be effective. The HCP should consider whether medical comorbidities, such as sleep Managing acute pain For acute pain, non-opioids may offer effective management and should be utilized preferentially, alone or in combination with opioids (when indicated) to increase pain control and spare opioid doses. 25 Much acute pain is manageable with rest, over-the- counter medications, or a short course of opioids and resolution of the underlying cause (e.g., trauma, surgery, illness). Objective signs of an acute, painful medical condition (e.g., bone fracture or imaging that reveals kidney stones) are examples for when opioids are likely indicated. Prompt management of acute pain is necessary to prevent progression to a chronic state. 25 When opioids are indicated, the therapeutic goal is to prescribe the lowest dose that controls pain for a duration lasting only as long as the acute phase. Leftover pills from acute pain prescriptions may later become a chief source of diverted and misused opioids. A systematic review found that 42% to 71% of opioids obtained by surgical patients went unused. 94 Prescriptions beyond three days are usually unnecessary, 64 while more severe episodes rarely need more than 7-14 days, although there are exceptions. 64,86 Be aware that localities and states may have strict regulations governing maximum duration of prescriptions for acute pain. In nearly all cases, HCPS should not prescribe ER/LA opioids for acute pain. It is worth considering that long-term opioids typically are not recommended for nonspecific back pain, headaches, or fibromyalgia, if the HCP should
apnea, may increase risk of respiratory depression, whether other available therapies have better or equal evidence, and whether thorough patient evaluation indicates the patient is likely to adhere to the treatment plan. Treatment plans should be revisited and adjusted frequently to ensure goals are being met and any adverse effects of therapy are addressed. The success of a pain management plan is highly dependent on the therapeutic alliance established between the patient and the HCP. see a patient experiencing acute pain flares occurring with these conditions. 23 Be aware also that patients who seek opioids to misuse may utilize emergency departments or urgent care for this purpose. The American College of Emergency Physicians (ACEP) has identified acute low back pain and exacerbations of chronic pain as common presenting complaints in the emergency department and recommends assessing whether nonopioid therapies would be adequate pain treatment, reserving opioids for severe pain that would be unresponsive to other therapies. 95 If opioids are indicated, the ACEP recommends prescribing the lowest practical dose for the shortest duration, considering the patient’s risk for opioid misuse or diversion. 95 Checking the state prescription database ahead of prescribing opioids for acute pain can help ensure the patient is receiving the appropriate quantity of opioids for the pain. 3 If pain from surgery or trauma persists beyond the expected healing period, HCPs should reevaluate the diagnosis and treatment plan. Self-Assessment Question 6 Which percentage of people who misuse opioids get them by prescription from one doctor?
a. 10% b. 25% c. 33% d. 50%
Assessing the risk of transition from acute to chronic pain Most cases of chronic pain begin as acute pain, and evidence suggests that prolonged exposure to pain leads to CNS changes that can transform the experience to a chronic syndrome. 25 Studies suggest that one-third of patients have progressively worsening pain intensity postoperatively, 25 and
most research on risk factors for transitioning from acute to chronic pain takes place in surgical settings. Established risk factors include younger age, female gender, catastrophizing, low socioeconomic status, preoperative pain, impaired diffuse noxious inhibitory control, type and duration of surgery, injury to specific
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Book Code: MDCO1025
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