Table 5: Chronic pain patients vs. patients with an OUD 137
Patient with chronic pain
Patient with an opioid use disorder
Medication use is not out of control
Medication use is out of control
Medication use improves quality of life Wants to decrease medication if adverse effects develop Is concerned about the physical problem being treated with the drug Follows the practitioner-patient agreement for use of the opioid
Medication use impairs quality of life
Medication use continues or increases despite adverse effects
Unaware of or in denial about any problems that develop as a result of drug treatment
Does not follow opioid agreement
May have left over medication
Does not have leftover medication Loses prescriptions Always has a story about why more drug is needed
Signs of physical dependence include the appearance of an abstinence syndrome with abrupt cessation or diminution of chronic drug administration and is not the same as OUD, a condition where patients lose control of their opioid use or compulsively use opioids. The nature and time of onset of this syndrome vary with drug actions and half-life. Slow tapering of the drug (e.g., 10-15% reduction in dosage per day or every other day) usually avoids the appearance of an abstinence syndrome. Managing Non-Adherent Patients Patients who exhibit aberrant drug-related behaviors or non-adherence to an opioid prescription should be monitored more closely than compliant patients. Concern that a patient is non-adherent should prompt a thorough evaluation. The way clinicians interact with patients can affect the relationship (for better or worse) and influence treatment outcomes. A clinician’s negative reactions to non-adherence might include anger at the patient, disappointment and sadness at the apparent betrayal of trust, or fear that the patient’s behavior could expose the provider to legal jeopardy. 104 The use of patient–provider agreements and/or informed consent documents can help clinicians navigate the uncertainties that can arise in cases of real or apparent non-adherence and may help make the process less confrontational. Consultation with an addiction medicine specialist or psychiatrist may be necessary if addiction is suspected or if a patient’s behavior becomes so problematic that it jeopardizes the clinician/patient relationship. Treatment Termination Reasons for discontinuing an opioid analgesic can include the healing of or recovery from an injury, medical procedure, or condition; intolerable side effects; lack of response; or discovery of misuse of medications. Regardless of the reason, termination should be accomplished so as to minimize unpleasant withdrawal symptoms by tapering the opioid medication slowly, by carefully changing to a new formulation, or by effectively treating an opioid use disorder if it has developed. Approaches to weaning
range from a slow 10% reduction per week to a more aggressive 25 to 50% reduction every few days. 28 In general, a slower taper will produce fewer unpleasant symptoms of withdrawal; however, this may not be the safe course of action for a patient experiencing side effects or who has OUD. Opioid therapy must be discontinued or re-evaluated whenever the risk of therapy is deemed to outweigh the benefits being provided. A clinician may choose to continue opioid treatment with intensified monitoring, counseling, and careful documentation if it is deemed in the best interest of the patient. This requires, however, careful consideration and a well-documented risk management plan that addresses the greater resources necessary for opioid continuation following evidence of misuse. If termination of the physician/patient relationship is deemed necessary (though it rarely is), clinicians must ensure that the patient is transferred to the care of another physician or provider and ensure that the patient has adequate medications to avoid unnecessary risk, such as from uncontrolled or unpleasant withdrawal. Practitioners can be held accountable for patient abandonment if medical care is discontinued without justification or adequate provision for subsequent care. Caution with dose escalation When escalating opioid doses, be aware of two possible critical daily thresholds—50 and 90 MMED. 34 According to the CDC, doses >50 MMED are associated with more than double the risk of overdose compared to patients on <50 MMED. 31 For patients on >90 MMED, a 9-fold increase in mortality risk was observed compared with the lowest opioid doses. Ninety MMED is considered by several guidelines as a “red flag” dose beyond which careful assessment, more frequent monitoring, and documentation of expected benefits are required (note, however, that this limit doesn’t apply to patients with severe cancer pain or end-of-life pain). The total MMED for all prescribed opioids should be used (MMED is automatically calculated on many state PDMP reports). Physician clinical judgment is also important
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Book Code: MDAZ1124
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