avoiding potentially dangerous drug interactions, and preventing diversion. Remind patients that opioid pain medications are frequently diverted, and opioids should be stored in a locked cabinet or other secure storage unit. If a locked unit is not available, patients should be advised to not keep opioids in an open place that is easily accessed by others, since theft by friends, relatives, and guests is a known route by which opioids become diverted. 115 Discuss the effects that opioids might have on ability to operate a vehicle, particularly when opioids are first started, when dosages are increased, or when other central nervous system depressants, such as Managing opioid-induced adverse effects An essential component of any chronic opioid therapy follow-up evaluation is assessment for opioid-related adverse effects. Tolerance to acute opioid-induced side effects (e.g., sedation, nausea/vomiting, itching) will develop; however, other adverse effects may continue to be an issue. Additionally, clinicians must be aware of long-term side effects. Opioid-induced constipation is a risk throughout chronic opioid therapy. Therefore, prescribing scheduled use of stool softeners (e.g., docusate) and stimulants for those receiving chronic opioids is warranted. In addition, instruct patients to contact their prescriber if they do not have a bowel movement at least every 2 to 3 days to avoid developing impaction. In some cases, a prescription medication for opioid-induced constipation may be necessary. Patients do not develop tolerance to the opioids’ respiratory depressive effects, even with chronic therapy. Additionally, this risk increases if other CNS depressant agents (prescribed or illicit) or alcohol are concurrent. It is strongly recommended to prescribe naloxone (Narcan), an opioid antagonist, for any patient at risk of opioid-induced respiratory depression. Narcan is safe and effective and instructions for use should be given not only to the patient but also to any family members or acquaintances who may have the opportunity to use naloxone in the setting of an overdose. Narcan has no significant physiologic effect if given to a patient who has not used opioids and can be given safely in almost any patient with undifferentiated altered mental status. When administered to a patient experiencing an opioid overdose and opioid-induced respiratory depression, naloxone can rapidly reverse all signs and symptoms of opioid intoxication. Many states have passed laws expanding access to naloxone, allowing pharmacists to dispense or distribute naloxone without a prescription under certain circumstances. As part of the FDA’s action plan regarding the safety of opioid analgesics, it has released several safety- related product labeling updates. In addition, the FDA updated warnings across the entire class of opioids regarding drug interactions, adrenal issues, and alterations in sex hormone levels. 117 Specifically, the FDA warns that opioids may interact with other medications that increase serotonin levels (e.g., certain antidepressants and migraine medications), which may lead to serotonin syndrome. In addition,
benzodiazepines or alcohol, are used concurrently. Proper disposal methods should be explained. Common instructions include the recommendation to not flush medications down the sink or toilet unless the prescribing information specifically instructs to do so. Many pharmacies, health centers, police stations and other organizations have take-back programs, including tamper-proof drop-off containers. Mixing the medicine with an undesirable substance such as coffee grounds or kitty litter for disposal in the trash is another option. 116 Commercial disposal systems such as DisposeRX have been developed and represent a safe way to dispose of these medications. opioids are rarely associated with adrenal insufficiency, and long-term use of opioids decreases sex hormone levels. Consider these potential drug interactions and adverse effects and discuss them with patients when determining the appropriateness of opioid therapy. 118 The FDA issues a BBW for all prescription opioid pain and cough medications and all prescription benzodiazepines regarding the risk for the CNS depression and serious adverse effects, including respiratory depression and death. The BBW was issued after several studies showed an increasing trend in concomitant dispensing of opioid analgesics and benzodiazepines and an increasing frequency of combined benzodiazepine and prescription opioid misuse, abuse, and overdose as measured by national emergency department visit and overdose death rates from prescribed or greater-than-prescribed doses. 119 In addition, other CNS depressants (e.g., barbiturates, antipsychotics, and neuroleptic drugs; antiepileptic and antiparkinsonian drugs; anesthetics; autonomic nervous system drugs; and muscle relaxants) contributed to deaths where opioids were also implicated. 120 It has been documented that alcohol and benzodiazepine coinvolvement in opioid-involved overdose deaths was common, varied by opioid subtype, and was associated with state-level binge drinking and benzodiazepine prescribing rates. 121 The FDA states that clinicians should limit prescribing opioid pain medicines with benzodiazepines or other CNS depressants only to patients with inadequate alternative treatment options. Avoid prescribing opioid-containing cough medicines to patients taking benzodiazepines or other CNS depressants, including alcohol. When prescribing medications, limit dosages and the duration of each drug to the least possible while achieving the desired clinical effect. Counseling patients regarding possible adverse severe reactions is critical. Despite the warnings, the use of other sedative medications is not an absolute contraindication when patients are using certain opioid medications. The FDA clarified this warning for patients taking opioid- addiction medications. Specifically, the FDA advised that the opioid-addiction medications buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the CNS. Although the combined use of these drugs
Book Code: MDCO1025
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