increases the risk of severe side effects, the harm caused by untreated opioid addiction can outweigh these risks. These medications are often used with counseling and behavioral therapies for patients undergoing treatment with medications for opioid Tapering of chronic opioid therapy Sometimes, clinicians must decide whether to decrease or discontinue chronic opioid therapy. Many factors may contribute to this decision: Patient request; lack of response; signs of substance abuse disorder, overdose, or other serious adverse events; or early signs of overdose risk. Therefore, any tapering schedule must be patient-specific to minimize withdrawal symptoms while maintaining adequate pain management. A general recommendation is to begin with a 10% decrease of the initial dose per week. Some patients who have taken opioids for a long time may require slower tapers (e.g., 10% per month). Adjust the rate and duration of the taper based on the patient’s response. It is advisable to slow or pause a taper to manage withdrawal symptoms rather than reversing the taper. It is essential to discuss the risk of overdose if a patient quickly returns to a prescribed higher Nonopioid pain treatment Nonopioid pain management is an important tool in the war against both acute and chronic pain. The Alternatives to Opiates (ALTO) program was launched in 2016 at St. Joseph’s Regional Medical Center in Paterson, New Jersey. This program was novel at the time and used targeted nonopioid medications, trigger-point injections, nitrous oxide, and ultrasound- guided nerve blocks to tailor its patients’ pain management needs and avoid opioids when possible. According to their website, the hospital reduced opioid use by 50% since the inception of the program. 113 The ALTO program has matured, and other institutions have implemented similar programs. The Colorado ALTO project has a toolkit with specific recommendations for the treatment of acute and nonacute pain. It is accessible at https://cha.com/ wp-content/uploads/2018/04/Colorado-ALTO-Project- Clinician-Toolkit.pdf. This project, initially designed and tested on patients presenting to the ED, has categories of patients
use disorder (MOUD), and patients can be treated with them indefinitely. Careful patient monitoring is necessary when prescribing benzodiazepines or other CNS-depressant agents in combination with MOUD and appropriate and continued patient counseling. 122 dose. Consider prescribing naloxone to reverse possible overdose symptoms. After achieving the smallest available dose, the interval between opioid doses increases, and opioids stop when taken less than once a day. Patients at high risk of harm, such as pregnant women or those with substance abuse disorder, may require coordination with treatment experts. Withdrawal symptoms are especially concerning in pregnant patients due to the risks to the mother and fetus. It is crucial to ensure patients receive appropriate encouragement and psychosocial support, including consultations with mental health providers and treatment for opioid use disorder as needed. Reassure patients that most people have improved function, without worse pain, after tapering opioids. In addition, some patients experience less pain after a taper, even though the pain may worsen initially. organized by pain type within the toolkit. It can be used by all providers to treat various types of pain in the ED, inpatient, and outpatient setting. Other clinical applications guides are available and include specific recommendations for treatment regimens depending on the acute complaint in the ED. The use of NSAIDs, skeletal muscle relaxants, and topical medications is very common. More recent additions include the use of low dose ketamine and haloperidol in the treatment of acute pain in the Emergency Department setting. 114 The American Academy of Pain Medicine developed a clinical practice guideline for use in the treatment of pain that can be reviewed on their website: https:// painmed.org/clinical-guidelines/. A comprehensive report on pain management practices can be found on the U.S. Department of Health and Human Services website: https://www.hhs.gov/opioids/prevention/ pain-management-options/index.html.
Case study 5 Taylor is a 30-year-old plumber who is currently on medical leave after a work-related accident. He required surgery on his ankle that involved implantable hardware. Taylor was prescribed a short-acting opioid after each surgery, which he has continued to use due to difficulty completing his prescribed physical therapy. He is requesting an ER/LA opioid since the short-acting medication, he says, is not relieving his pain completely between doses. He says friends have suggested that a long-acting opioid would be easier to use and would provide him more steady pain relief. Questions 1. What options exist prior to prescribing a trial of ER/LA medication? _______________________________________________________________________________________________ 2. What functional goal would be reasonable to discuss prior to a pain agreement with Zeke? _______________________________________________________________________________________________ 3. What cautions would you provide to this patient if you decided to give a trial of an ER/LA opioid? _______________________________________________________________________________________________
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Book Code: MDCO1025
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