in determining daily thresholds and the CDC limits can be used as a guide. Role of ER/LA opioids and methadone ER/LA opioids include methadone, transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine. A 2015 study found a higher risk for overdose among patients initiating treatment with ER/LA opioids than among those initiating treatment with immediate-release opioids. 124 As noted above, continuous, time-scheduled use of ER/LA opioids is not more effective or safer than intermittent use of immediate-release opioids, and ER/ LA opioids increase risks for opioid misuse or addiction. 31 The 2022 CDC guidelines suggest that ER/LA opioids should be reserved for severe, continuous pain and should be considered only for patients who have received immediate-release opioids daily for at least 1 week. Additional caution is required when prescribing ER/LA opioids in older adults or patients with renal or hepatic dysfunction because decreased clearance of drugs among these patients can lead to accumulation
of drugs to toxic levels and persistence in the body for longer durations. When an ER/LA opioid is prescribed in the primary care setting, using an agent with predictable pharmacokinetics and pharmacodynamics is preferred to minimize unintentional overdose risk (i.e., the unusual characteristics of methadone and transdermal fentanyl make safe prescribing of these medications for pain more challenging). 31 The use of methadone for chronic pain in primary care should generally be avoided because of higher methadone-related risks for QTc prolongation and fatal arrhythmias. 31 Equianalgesic dose ratios are highly variable with methadone, making conversion from other opioids difficult, with attendant increased risk of overdose. While methadone-related death rates decreased 9% from 2014 to 2015 overall, the rate increased in people ≥65 years of age. 139 If methadone or transdermal fentanyl is considered, refer patients to pain management specialists with expertise in using this medication.
Case study 5 Jeremiah has been your patient since he was a young boy. Now 33 years old, you have seen Jeremiah grow up into a physically strong, but emotionally vulnerable young man. Jeremiah struggled in school and chose to enter a training program for masons rather than pursue college. A self-described “partyer” who reports regular use of alcohol and cannabis, Jeremiah nonetheless has not reported any impacts of his substance use on his personal or work life. He has, in fact, been successful in both, earning a good living as a mason and supporting his wife and two sons. But Jeremiah is currently on workman’s compensation to recover from a compound fracture of his left foot and ankle sustained when a large section of a chimney he was working on collapsed and fell. He also tore the rotator cuff in his right shoulder when he fell backwards against the scaffolding poles during the accident. Both injuries required surgical interventions and his recovery has been slow. Jeremiah was prescribed a short-acting opioid after each surgery, which he has continued to use. He has been regularly attending physical therapy sessions to restore strength in his left leg and to increase the range of motion in his right shoulder, but he complains that the therapy sessions are painful and that he doesn’t think they’re helping. He says his boss suggested that a long-acting opioid would be easier to use and would provide him more steady pain relief. Questions: 1. How would Jeremiah’s substance use affect your decision-making process related to his request for an ER/LA medication? ______________________________________________________________________________________________ 2. What steps might you take before agreeing to a trial of an ER/LA medication for Jeremiah? _______________________________________________________________________________________________ 3. What specific kind/dose of ER/LA medication might be most appropriate for Jeremiah if no contraindications were found in the pain and substance abuse assessment? _______________________________________________________________________________________________ 4. Name three specific functional goals that might be used as the basis for a pain management agreement with Jeremiah. _______________________________________________________________________________________________
Book Code: MDAZ1124
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