● Potential risks and benefits of opioid therapy. ● Risks of OUD, overdose, and death even at prescribed doses. ● That evidence is limited for benefit of opioids in chronic noncancer pain. ● A mention of nonpharmacologic and nonopioid therapeutic options for pain treatment. ● Potential short- and long-term side effects, such as cognitive impairment and constipation. ● The likelihood that tolerance and physical dependence will develop. ● Risks of drug interactions. Opioid treatment agreements Opioid treatment agreements that spell out patient and HCP expectations and responsibilities are recommended by most opioid guidelines. 78,86 Consider including: 134 ● Treatment goals in terms of pain management, restoration of function, and safety. ● Patient’s responsibility for safe medication use, such as agreement not to take more than prescribed, alter pills, or combine with alcohol, unauthorized prescriptions, or illicitly obtained drugs. ● Patient’s responsibility to obtain prescribed opioids from only one HCP or practice. ● Patient’s responsibility to fill prescriptions at only one pharmacy. ● Patient’s agreement to periodic UDT or other drug tests. ● Instructions for secure storage and safe disposal of prescribed opioids. ● HCP’s prescribing policies, including handling of early refills and replacing lost or stolen medications. ● Reasons for which opioid therapy may be changed or discontinued, including violation of the treatment agreement. Managing side effects HCPs should expect, prevent, and take steps to manage opioid-related adverse effects. Common
● Risks of impaired motor skills affecting driving, operating machinery, and other tasks. ● Signs and symptoms of overdose. ● Risks when combining opioids with other CNS- depressants, including benzodiazepines and alcohol. ● The importance of the patient disclosing all medications and supplements. ● How to handle missed doses. ● Any important product-specific risks, such as the dangers of chewing an ER formulation. ● Statement that treatment may be discontinued without the patient’s agreement. ● HCPs availability policy, including responsibility to provide care for unforeseen problems and to prescribe scheduled refills. ● Education that the patient should not expect complete elimination of pain. ● The patient’s signature. The forms for informed consent and treatment agreements may be combined into one document and adapted to the HCP’s needs and preferences. Examples of informed consent and treatment agreement documents are available online from the New Hampshire Medical Society at https://www.nhms. org/opioid-prescribing-resources. Both forms can help facilitate discussions with the patient about ongoing risks and benefits and also provide structure in case difficult conversations become necessary regarding adherence to the treatment regimen. It is advisable to have a strategy to manage opioid misuse by the patient should it occur and to know and discuss with the patient indications for which opioid therapy may be discontinued.
opioid side effects with suggested management strategies are listed in Table 7. 78
Table 7: Common Opioid Side Effects and Suggested Management Strategies Side Effect Management Respiratory depression • Screen for sleep apnea.
• Avoid sedatives, benzodiazepines, barbiturates, and alcohol.
Constipation
• Increase fiber and fluids; start prophylactic laxative treatment, particularly in older patients.
Nausea or vomiting Hormonal deficiencies Sedation, mental clouding
• Antiemetic therapy; symptoms tend to diminish.
• Screen symptomatic patients (fatigue, sexual dysfunction).
• Counsel as to home, work and driving safety, and concomitant CNS- depressant risks; symptoms tend to diminish. • Treatments largely anecdotal (may include reducing dose, changing medication).
Pruritis
Hyperalgesia
• Reduce dose or change medication.
Book Code: MDCO1025
Page 25
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