prescriber in the management of the patient’s pain and the discontinuation plan. The agreement should also address the risks and benefits of opioid therapy and address alternative treatment options. Treatment agreements should address risk mitigation strategies that may include, but are not limited to: ● Prescribing and Dispensing Controls (single prescriber, single pharmacy for refills); ● Random or routine drug testing; ● Restrictions on alcohol and/or illicit drug use; ● Random or routine pill counts; ● Storage, disposal, and diversion precautions (including detailed precautions related to adolescents and/or children and visitors to the home); and, ● Disclosure of alternative therapies.
the treatment plan, the reassessment schedule and referral to a specialist for pain management or suspected opioid use disorder. Prescribers should ensure the patient has a clear understanding of the treatment agreement using the patient education techniques previously discussed and by documenting the patient’s understanding in the medical record or through the patient’s signature on the treatment plan. See Appendix A.1 for resources on sample agreements. addition, concurrent naloxone prescriptions should be considered for patients receiving any prescription outlier for dosage, formulation or duration. Naloxone rescue prescriptions should be accompanied by patient and family member education regarding signs of overdose, administration of naloxone and activation of emergency medical services.
Treatment agreements should also address the process and reasons for changing or discontinuing Concurrent Naloxone Prescriptions Opioid overdose deaths may be preventable by the timely administration of naloxone. Several studies indicate that home naloxone programs are effective in decreasing overdose mortality and have a low rate of adverse events.15 Prescribers and dispensers should consider concurrent naloxone prescriptions 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. In Patient Education In addition to educating the patient prior to initiating opioid therapy, prescribers should incorporate patient education into each patient’s evaluation during opioid treatment. Education is particularly important prior to increasing dosage, extending treatment, changing formulations, upon learning of new factors that may lead to adverse outcomes and any change in the risk/benefit balance.
Prescribers should regularly re-educate patients regarding risks, benefits, side effects, alternative treatments, diversion and the safe use, and the storage and disposal of opioids. Pharmacists should offer to re-review information with the patient about risks, disposal, and other applicable topics with each refill.
DISCONTINUING OPIOID THERAPY
● The prescriber suspects diversion; or ● The prescriber suspects opioid misuse or abuse. The prescriber discontinuing opioid therapy should employ a safe, structured tapering regimen through the prescriber or an addiction or pain specialist. There is a risk of patients turning to street drugs or alcohol abuse if tapering is too rapid or is completed without appropriate support. See the Appendix for resources addressing tapering.
The prescriber should consider discontinuing opioid therapy when: ● The underlying painful condition is resolved; ● Intolerable side effects emerge; ● The analgesic effect is inadequate; ● The patient’s quality of life fails to improve; ● Functioning fails to improve or deteriorates; ● The risks of treatment outweigh the benefits; ● The patient overdoses; ● The patient demonstrates suicidality; ● Non-compliance with the treatment plan;
TREATMENT FOR OPIOID USE DISORDER
Opioid use disorder is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress, manifested by at least two defined criteria occurring within one year.17 Studies estimate that 2.1 million people in the United States suffer from substance abuse disorders related to prescription opioids.18 Medically Assisted Treatment (“MAT”) in combination with cognitive behavioral
therapy has been shown to reduce relapse in patients with opioid use disorder. 19 The identification of an opioid use disorder is an opportunity for the prescriber to collaborate with the patient to improve their safety and increase the likelihood of successful opioid use disorder treatment. Prescribers suspecting opioid use disorder should discuss their concerns with the patient and identify treatment resources for the patient.
Book Code: MDCO1025
Page 39
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