______________________________________________________ Opioid Safety: Balancing Benefits and Risks
partial agonist effect lessens. For patients receiving naltrexone for opioid use disorder, short-term use of higher-potency nono- pioid analgesics (e.g., NSAIDs) can be considered to manage severe acute pain. Patients receiving methadone for opioid use disorder who require additional opioids as treatment for severe acute pain management should be carefully monitored, and when feasible should optimally be treated by a clinician experienced in the treatment of pain in consultation with their opioid treatment program. [11]. The American Society of Addiction Medicine National Practice Guideline for the Treatment of Opioid Use Disorder (2020 Focused Update) provides additional recommendations for the management of patients receiving medications for opioid use disorder who have planned surgeries for which nonopioid therapies are not anticipated to provide sufficient pain relief [11]. RESPONSE TO THE CDC’S OPIOID PRESCRIBING GUIDELINE UPDATE It is important to note that the CDC’s guidelines are voluntary, and the changes may not result in changes to state laws and rules established to restrict opioid prescribing and help curb opioid misuse following publication of the 2016 guideline. The 2022 draft guideline emphasizes prescriber decision-making and access to necessary opioid analgesics to address unrelenting pain. The guideline states that some policies have extended even beyond the 2016 recommendations, contributing to patient harm, including untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior [2]. However, state governments seem reluctant to make similar changes, especially as opioid overdose deaths have increased [13]. The American Academy of Pain Medicine, which had expressed dismay with the 2016 CDC guideline and how it was misapplied by insurance companies, state governments, and healthcare organizations, indicated general support for the 2022 revision [14]. IDENTIFICATION OF DRUG DIVERSION/ SEEKING BEHAVIORS Urine drug tests can give insight into patients who are misusing opioids. A random sample of urine drug test results from 800 pain patients treated at a Veterans Affairs facility found that 25.2% were negative for the prescribed opioid while 19.5% were positive for an illicit drug/unreported opioid [15]. Nega- tive urine drug test results for the prescribed opioid do not necessarily indicate diversion but may indicate the patient halted his/her use due to side effects, lack of efficacy, or pain remission. The concern arises over the increasingly stringent climate surrounding clinical decision-making regarding aber- rant urine drug test results and that a negative result for the prescribed opioid or a positive urine drug test may serve as the pretense to terminate a patient rather than guide him/ her into addiction treatment or an alternative pain manage-
ment program; the CDC states that “clinicians should not dismiss patients from care on the basis of a toxicology test result. Dismissal could have adverse consequences for patient safety, potentially including the patient obtaining opioids from alternative sources and the clinician missing opportunities to facilitate treatment for a substance use disorder” [2]. In addition to aberrant urine screens, there are certain behav- iors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [4; 16; 17]: • Selling medications • Prescription forgery or alteration • Injecting medications meant for oral use • Obtaining medications from nonmedical sources • Resisting medication change despite worsening function or significant negative effects • Loss of control over alcohol use • Using illegal drugs or non-prescribed controlled substances • Recurrent episodes of: ‒ Prescription loss or theft ‒ Obtaining opioids from other providers in violation of a treatment agreement ‒ Unsanctioned dose escalation ‒ Running out of medication and requesting early refills Behaviors with a lower level of evidence for their association with opioid misuse include [4; 16; 17]: • Aggressive demands for more drug • Asking for specific medications • Stockpiling medications during times when pain is less severe • Using pain medications to treat other symptoms • Reluctance to decrease opioid dosing once stable • In the earlier stages of treatment: ‒ Increasing medication dosing without provider permission ‒ Obtaining prescriptions from sources other than the pain provider ‒ Sharing or borrowing similar medications from friends/family
inter active activity
View the CDC’s video Risk Factors in Opioid Prescribing at https://www.netce.com/learning.php?page=activit ies&courseid=3207. This video addresses the various risk factors likely to increase susceptibility to opioid- associated harms and suggests strategies for mitigating these risks.
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