● Do not abruptly discontinue opioid analgesics in patients physically dependent on opioids. Counsel patients not to discontinue their opioids without first discussing the need for a gradual tapering regimen. ● Abrupt or inappropriately rapid discontinuation of opioids is associated with serious withdrawal symptoms, uncontrolled pain, and suicide. ● Ensure ongoing care of the patient and mutually agree on an appropriate tapering schedule and follow-up plan. ● In general, taper by an increment of no more than 10-20% every 2-4 weeks. ● Pause taper if the patient experiences significantly increased pain or serious withdrawal symptoms. ● Use a multimodal approach to pain management, including mental health support (if needed). ● Reassess the patient regularly to manage pain and withdrawal symptoms that emerge and assess for suicidality or mood changes. ● Refer patients with complex comorbidities or substance use disorders to a specialist.
reduction or discontinuation resulted in reduced pain (eight studies), improved function (five studies) and improved quality of life (three studies), although the evidence was not strong because the analysis included poor-quality studies with uncontrolled designs and the interventions and outcome measures were heterogeneous. 142 Recommendations for tapering schedules vary. One source recommends a 10% decrease weekly based on years of opioid use (i.e., 10% decrease monthly for patients using opioids ≥4 years). For patients on high- dose opioids (i.e., ≥90 MMED), taper 10% until patient is taking 30% of the total initial dose, then recalculate 10% taper based on the new total opioid dose to slow taper. 143 The rate of opioid taper should be adjusted based on patient-specific factors such as the severity of withdrawal symptoms. In 2019 the FDA, recognizing the risks associated with abrupt discontinuation of opioid analgesics, required new labeling for opioid analgesics to guide prescribers about safe tapering practices. 138 The key elements include: 144
OPIOID USE DISORDER (OUD)
● Giving up enjoyable social, work, or recreational activities due to opioids ● Recurrent opioid use in situations in which it is physically hazardous (e.g., driving) ● Continued use despite a physical or psychological problem caused by or worsened by opioid use ● Tolerance (unless opioids are being taken as prescribed) ● Using opioids to prevent withdrawal symptoms (unless opioids are being taken as prescribed) OUD is not a binary diagnosis, rather it exists as a continuum, with DSM-5 describing 3 levels of severity: ● Mild OUD (2-3 criteria) More than 2 million Americans have OUD, and the number is growing. 70 OUD can be effectively managed with medication-assisted treatment (MAT), but only an estimated 20% of adults with OUD currently receive such treatment. 146 unique mechanism of action and involve different formulations, methods of induction and maintenance, patterns of administration, and regulatory requirements. ● Moderate OUD (4-5 criteria) ● Severe OUD (≥ 6 criteria)
OUD is a problematic pattern of opioid use that causes significant impairment or distress. 145 As with other chronic diseases, OUD usually involves cycles of relapse and remission. DSM-5 diagnosis of OUD is based on clinical evaluation and determination that a patient has problematic opioid use leading to clinically significant impairment or distress involving at least two of the following within a 12-month period: 145 ● Opioids taken in larger amounts, or for longer periods, than intended ● Persistent desire or unsuccessful attempts to control or reduce use ● Significant time lost obtaining, consuming, and recovering from opioids ● Craving or a strong desire or urge to use opioids ● Failure to complete obligations (i.e., work, home, or school) due to opioids ● Persistent or recurrent social or interpersonal problems due to opioids Medications to treat OUD The FDA has approved three medications for treating OUD: buprenorphine, methadone, and extended- release naltrexone (Table 7). Buprenorphine and methadone can reduce opioid cravings and all three can prevent misuse. 141 Each medication has a
Book Code: MDAZ1124
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