Problematic opioid use Although evidence for the long-term effectiveness of opioids for chronic pain is weak, evidence for opioid- related harms is abundant and strong. In 2016, 11.5 million people self-reported that they had personally misused prescription opioids during the previous year. It is important to recognize and differentiate problematic use from adverse side effects of opioids. For instance, tolerance and opioid withdrawal occur with long term use of prescribed opioids. Clinicians should be able to differentiate this from problematic use.
Abrupt cessation of tramadol is associated with opioid withdrawal, restlessness, and drug cravings (similar to those associated with other opioids) as well as hallucinations, paranoia, extreme anxiety, panic attacks, confusion, and numbness/tingling in extremities (which are less typical of other opioids). 85 Tapentadol is FDA-approved for treating neuropathic pain associated with diabetic peripheral neuropathy, although it is also used for musculoskeletal pain. During treatment, tapentadol reduced pain intensity more than placebo.
Table 2. Behaviors indicative of opioid misuse 9 Behavior
Frequency in patients with opioid misuse
Requested early refills Increased dose on own
47% 39% 35% 26% 18%
Felt intoxicated from pain medication
Purposely over sedated oneself
Used opioids for purpose other than pain
Among adults without a prescription, 41% obtained prescription opioids from friends or relatives for their most recent episodes of misuse. 87 For prescription opioids, long-term therapy is associated with an increased risk in accidental
overdose and death. A retrospective study including 9,940 patients who received three or more opioid prescriptions within 90 days for chronic pain between 1997 and 2005 found that annual overdose rates rose significantly as doses exceeded 50 MMED (Figure 4). 88
Figure 4. Risk of overdose rises with daily milligram morphine-equivalent dose. 88
Combining opioids with sedating drugs such as benzodiazepines or alcohol increases the risk of respiratory depression and overdose death. 34 Benzodiazepines have been linked with overdose fatalities in 50-80% of heroin overdoses, and 40- 80% in methadone-related deaths. 34,89 Patients prescribed benzodiazepines who are being initiated
on opioids should have their benzodiazepine tapered and discontinued whenever possible. For patients being co-managed by mental health professionals, coordinate a plan regarding continuing or tapering benzodiazepines in the setting of opioid co- prescribing.
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Book Code: MDAZ1124
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