Initiating opioid therapy for chronic noncancer pain When initiating opioid therapy for chronic pain, clinicians should start with immediate-release opioids and avoid extended-release formulations or long- acting opioids. Begin with the lowest effective dosage. Evaluate patients within 1 to 4 weeks of starting opioid therapy or dose escalation. Clinicians should evaluate patients every 3 months to assess the continued benefit and the development of any adverse effects once the opioid dose is stabilized. If the patient no longer benefits from the opioid therapy, the clinician should optimize the treatment regimen, including adding other treatment modalities or tapering off the opioid regimen. 105 Some patient populations and patients with certain conditions require closer monitoring and counseling before initiation and during chronic pain treatment. For example, patients receiving other central nervous system depressants, especially benzodiazepines, require special attention because of an increased risk of adverse events, including increased sedation, confusion, difficulty driving or performing other tasks requiring high concentration levels, respiratory depression, and overdose. It is also necessary to assess how the patient uses work equipment that products, review FDA-approved risk evaluation and mitigation strategies (REMS) programs, medication guides, and black box warnings. 106 These products, listed in Table 11 on the next page, are not for acute pain, pain that is mild or not expected to persist for an extended period, or use on an as-needed basis. In addition, the FDA-approved black-box warnings (BBWs) on these products advise clinicians of the following: ● ER/LA opioid analgesics expose users to addiction, abuse, and misuse risks, leading to overdose and death. Assess each patient’s risk before prescribing and regularly monitor for the development of these behaviors and conditions.
requires precise motor control, heavy machinery, or chemical or biohazardous materials. Pregnant women also require an enhanced level of caution because chronic opioid use during pregnancy increases the risk of harm to the newborn, specifically neonatal opioid withdrawal syndrome. Further, these medications must be used cautiously in breastfeeding women because some opioids can be transferred to breast milk and may cause sedation or respiratory depression in the nursing infant. In elderly patients, clinicians should consider employing a lower starting dose, a slower titration period, and a longer dosing interval with more frequent monitoring. Patients with psychiatric disorders are at increased risk of adverse events associated with chronic opioid therapy. Untreated depression and other mental health disorders place patients at increased risk for misuse and abuse of opioid analgesics, including addiction and overdose. In addition, untreated depression may interfere with pain resolution. In cases where the opioid dosage increases, the prescriber should educate the patient on the risk of cognitive impairment that can negatively impact their ability to drive or perform other activities. ● Life-threatening severe or fatal respiratory depression may occur. Monitor closely, primarily upon initiation or following a dose increase. Instruct patients to swallow ER/LA opioid analgesics to avoid exposure to/ingestion of a potentially fatal dose. ● Accidental ingestion of ER/LA opioid analgesics can result in a fatal overdose, especially in children. ( Note: Accidental pet ingestion has also led to deadly consequences.) ● Prolonged ER/LA opioid analgesics use during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated. In prolonged opioid use in pregnant women, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure appropriate treatment will be available. ● Initiation of CYP 3A4 inhibitors (or discontinuation of medications that induce CYP 3A4) can result in a fatal overdose.
Special considerations for extended-release and long-acting (ER/LA) opioids The FDA advises that extended-release and long- acting (ER/LA) opioid analgesics be reserved for patients when alternative treatment options are ineffective, not tolerated, or inadequate to provide sufficient pain relief. Before prescribing these
Book Code: MI24CMEB
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