______________________________________________________ Opioid Safety: Balancing Benefits and Risks
• Toxicology results will inform decisions with major clinical or nonclinical implications for the patient • A need exists to detect specific opioids or other drugs within a class, such as those that are being prescribed, or those that cannot be identified on standard immunoassays • A need exists to confirm unexpected screening toxicology test results Restricting confirmatory testing to situations and substances for which results can reasonably be expected to affect patient management can reduce costs of toxicology testing. Clinicians might want to discuss unexpected results with the local laboratory or toxicologist and should discuss unexpected results with the patient. Clinicians should discuss unexpected results with patients in a nonjudgmental manner, avoiding use of potentially stigmatizing language (e.g., avoid describing a specimen as testing “clean” or “dirty”). Discussion with patients prior to specific confirmatory testing can sometimes yield a candid explanation of why a particular substance is present or absent and remove the need for confir- matory testing during that visit. For example, a patient might explain that the test is negative for prescribed opioids because they felt opioids were no longer helping and discontinued them. If unexpected results from toxicology screening are not explained, a confirmatory test on the same sample using a method selective enough to differentiate specific opioids and metabolites (e.g., gas or liquid chromatography/mass spectrometry) might be warranted. Clinicians should use unexpected results to improve patient safety (e.g., optimize pain management strategy [see Recom- mendation 2], carefully weigh benefits and risks of reducing or continuing opioid dosage [see Recommendation 5], re-evaluate more frequently [see Recommendation 7], offer naloxone [see Recommendation 8], and offer treatment or refer the patient treatment with medications for opioid use disorder [see Rec- ommendation 12], all as appropriate). Recommendation 11 Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depres- sants (recommendation category: B, evidence type: 3). Implementation Considerations Although in some circumstances it might be appropriate to prescribe opioids to a patient who is also prescribed benzodi- azepines (e.g., severe acute pain in a patient taking long-term, stable low-dose benzodiazepine therapy), clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently. In addition, clinicians should consider whether benefits outweigh risks of concurrent
use of opioids with other central nervous system depressants (e.g., muscle relaxants, non-benzodiazepine sedative hypnot- ics, potentially sedating anticonvulsant medications such as gabapentin and pregabalin). Buprenorphine or methadone for opioid use disorder should not be withheld from patients taking benzodiazepines or other medications that depress the central nervous system. Clinicians should check the PDMP for concurrent controlled medications prescribed by other clinicians (see Recommenda- tion 9) and should consider involving pharmacists as part of the management team when opioids are co-prescribed with other central nervous system depressants. In patients receiving opioids and benzodiazepines long-term, clinicians should carefully weigh the benefits and risks of con- tinuing therapy with opioids and benzodiazepines and discuss with patients and other members of the patient’s care team. Risks of concurrent opioid and benzodiazepine use are likely to be greater with unpredictable use of either medication, with use of higher-dosage opioids and higher-dosage benzodiazepines in combination, or with use with other substances including alcohol (compared with long-term stable use of lower-dosage opioids and lower-dosage benzodiazepines without other substances). In specific situations, benzodiazepines can be beneficial, and stopping benzodiazepines can be destabilizing. If risks are determined to outweigh benefits of continuing opioid and benzodiazepine therapy at current dosages and a decision is made to taper, it might be safer and more practical to taper opioids first. There can be greater risks of benzodiazepine withdrawal relative to opioid withdrawal, and tapering opioids can be associated with anxiety (see Recommendation 5). Clinicians should taper benzodiazepines gradually prior to discontinuation because abrupt withdrawal can be associ- ated with rebound anxiety, hallucinations, seizures, delirium tremens, and, rarely, death. The rate of tapering should be individualized. If benzodiazepines prescribed for anxiety are tapered or dis- continued, or if patients receiving opioids require treatment for anxiety, evidence-based psychotherapies (e.g., CBT) and/or specific antidepressants or other nonbenzodiazepine medica- tions, or both, approved for anxiety should be offered. Clinicians should communicate with other clinicians manag- ing the patient to discuss the patient’s needs, prioritize patient goals, weigh risks of concurrent benzodiazepine and opioid exposure, and coordinate care. Recommendation 12 Clinicians should offer or arrange treatment evidence-based medications to treat patients with opioid use disorder. Detoxi- fication on its own, without medications for opioid use disor-
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