the next step is a quantitative evaluation, usually via gas chromatography/mass spectrometry (GC/ MS) technology or liquid chromatography dual mass spectrometry (LC/MS/MS). These tests can detect actual drugs and their metabolites. Some laboratories offer definitive testing via LC-MS/MS that may be given as the initial test; however, most guidelines still suggest immunoassay ahead of confirmatory testing due to cost concerns. 130 A query of the state prescription drug monitoring program (PDMP) should also take place before opioids are initiated or continued. 23,64,78 These important checks of the patient’s past and present opioid prescriptions are done at initial assessment and during the monitoring phase. PDMP data can help to
identify patients who have had multiple practitioner episodes or potentially overlapping prescriptions that place them at risk of a misuse or drug interaction problem. The use of an PDMP is also aimed at stopping the spread of opioid misuse and diversion as a public health problem. If baseline UDT and PDMP checks indicate unauthorized prescriptions or there are other signs suggestive of opioid misuse, the results should be discussed with the patient and, if OUD or another substance-use issue is suspected, treatment should be offered and/or a specialist referral can be given. More will follow on using UDT and PDMP checks for periodic monitoring during the course of opioid therapy.
Case study 2 Jonathan, 42, presents looking anxious and in considerable pain. A year ago, while moving furniture, he experienced sudden piercing mid-lowback pain that radiated down his left leg. The patient had an L4/5 microdiscectomy that appeared at first to relieve radicular symptoms, but thesymptoms returned 6 weeks afterward. His pain intensity at rest is 6 out of 10 on the VAS, but movement brings on back spasms, which causeshis pain level to spike to 9 out of 10. Walking and bending at the waist are excruciating, and he finds it hard to find a comfortable position whenlying down. He reports that ACET and ibuprofen bring no relief and admits that he would like to receive an ER formulation of oxycodone becausehe already knows it works for the pain, having occasionally used the same prescription belonging to a friend. Jonathan is now estranged from hisparents, both of whom drank to excess and used illegal drugs when he was a child. He reports a history of panic attacks and nightmares eversince his time spent serving in the armed forces. He smokes approximately 30 cigarettes a day. He has no cardiopulmonary, gastrointestinal,endocrine, or neurologic diseases. Questions 1. How might Jonathan’s pain type, intensity, duration, and treatments tried inform the creation of a treatment plan for him? _______________________________________________________________________________________________ 2. What risk factors for opioid misuse are present and how might they influence treatment choices? _______________________________________________________________________________________________ 3. What mental health screening tool(s) would be helpful? _______________________________________________________________________________________________ Guidelines and regulations governing long-term opioid therapy
If, after a risk-benefit analysis, a trial of opioid therapy for chronic pain is warranted, HCPs have access to numerous guidelines developed by professional medical societies, states, and federal agencies to assist in setting and executing treatment plans. Common recommendations include: 23,64,78,86,131 ● Start patients on the lowest effective dose. ● Conduct UDT at baseline and on follow-up as appropriate. ● Check PDMP at baseline and on follow-up as appropriate. ● Monitor pain and treatment progress with documentation, using greater vigilance at higher doses. ● Pay close attention to drug-drug and drug-disease interactions. ● Recognize special risks with fentanyl patches and methadone. ● Titrate slowly and cautiously. ● Consider using an opioid-specific risk assessment ● Use safe and effective methods for discontinuing opioids (e.g., tapering, making appropriate referrals to substance abuse treatment or other services).
To dispense any controlled substance, including opioids, HCPs must be registered with the DEA. Be aware also that each state may have laws and regulations that govern many aspects of opioid prescribing. Each HCP should check the laws and regulations within the state of practice and take care to comply with all requirements. Applicable state regulations are evolving rapidly and contain restrictions and directives such as: 132 ● Dose and treatment duration limits. ● Expanded PDMPs and new requirements for their use. ● Required continuing medical education. ● Required written pain treatment agreements. ● Required physical exam prior to prescribing. ● Required bona fide patient-physician relationship. ● Specified timing of follow-up visits and/or UDT. ● Presentation of patient identification to a pharmacist prior to receiving opioids. ● Medicaid plans requiring single prescriber and single pharmacy for certain high-risk patients.
Book Code: MDCO1025
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