the treatment of acute pain, subacute pain or when initiating opioid therapy for chronic, non-cancer pain. Long-acting or extended relief opioids should be reserved for severe, continuous pain and should be considered for only those patients who have received immediate release opioids for at least one week.11 When prescribing long-acting or extended relief opioids, the prescriber should consider patient medications, including concurrent use of immediate Duration Long-term opioid use often begins with treatment of acute pain. When treating acute pain, prescribers should prescribe only the amount of medication needed for the expected duration of the pain. In most instances of non-traumatic or non-surgical pain, three days or less is sufficient, while more than seven days is rarely necessary.12 Prescribers must also be aware of the statutory limitations, in certain circumstances, on prescribing opioids for pain that has not been treated with an opioid over the previous twelve months as set forth in Senate Bill 18- 022, Clinical Practice for Opioid Prescribing. For longer-term opioid therapy for subacute pain 13 and the treatment of chronic, non-cancer pain, prescribers should note that contextual evidence suggests that patients who do not experience pain relief from opioids at 30 days are unlikely to experience relief at six months.13 Prescribers should reassess pain and function within 30 days of initiating
relief opioids, which may potentiate the effects of the opioid and health conditions that may affect that patient’s ability to process and excrete the drug. ● Providers should exercise caution when prescribing or dispensing transdermal fentanyl or methadone. See Appendix A.1 for information regarding methadone. therapy to minimize the risks of long-term opioid use for those patients receiving no clear benefit from opioid therapy. Continuing opioid therapy for over 90 days substantially increases the risk for opioid use disorder.14 As such, treatment for chronic non-cancer pain exceeding 90 days should be re-evaluated, assessing both the effectiveness of the therapy as measured by attainment of functional goals and weighing the benefits of the therapy against the risks to the patient. In those instances in which the benefits continue to outweigh the risks and the patient continues to show clinical improvement after 90 days of opioid therapy, prescribers and dispensers should implement additional risk mitigation strategies, if not already in place, as detailed below.
RISK MITIGATION STRATEGIES
Tools and Trials Prior to issuing prescriptions that are outliers to the dosage, formulation and duration guidelines, described herein, for chronic, non-cancer pain, prescribers should determine whether the opioid Referral to Pain Management Specialist Prior to issuing prescriptions that are outliers to the dosage, formulation or duration guidelines, as described herein, for chronic, non-cancer pain, prescribers should consult with, or consider referral of the patient to, a pain management specialist. Such Monitoring Opioid therapy for chronic, non-cancer pain requires regular monitoring by the prescriber. Monitoring should include: ● Reassessment of the patient’s pain, function, and risk; ● Rebalancing of the risks and benefits of continued opioid therapy; ● Rechecking the PDMP, and,
therapy has resulted in clinically significant improvement in pain and function and that the benefits of the therapy outweigh the risks to the patient. Opioid trials may assist in this determination. consultation or referral should also be considered for those patients at risk for respiratory depression, suicide or overdose and any patient concurrently prescribed medications such as benzodiazepines that are known to potentiate the effects of opioids. ● Conducting random and/or routine pill counts or drug screening according to the prescriber’s clinical assessment. These monitoring tools and others should be documented in a treatment agreement signed by the patient, described more below. Prescribers should not increase an initial opioid dosage without reassessing the patient’s pain, function and risk, rechecking the PDMP and rebalancing the risks and benefits of continued opioid therapy.
Treatment Agreements Prescribers should utilize treatment agreements (also commonly referred to as a plan or contract). Treatment agreements should incorporate
information from the patient’s longitudinal treatment plan including, the agreed upon pain and function goals, the responsibilities of the patient and the
Page 38
Book Code: MDCO1025
Powered by FlippingBook