entire class of opioids regarding drug interactions, adrenal issues, and alterations in sex hormone levels. Specifically, the FDA warns that opioids may interact with other medications that increase se- rotonin levels (e.g., certain antidepressants and migraine medica- tions), which may lead to serotonin syndrome. In addition, opioids are rarely associated with adrenal insufficiency, and long-term use of opioids decreases sex hormone levels. Consider these poten- tial drug interactions and adverse effects and discuss them with patients when determining the appropriateness of opioid therapy (FDA, 2022a). The FDA issues a black box warning (BBW) for all prescription opioid pain and cough medications and all prescription benzo- diazepines regarding the risk for the CNS depression and serious adverse effects, including respiratory depression and death. The BBW was issued after several studies showed an increasing trend in concomitant dispensing of opioid analgesics and benzodiaz- epines and an increasing frequency of combined benzodiazepine and prescription opioid misuse, abuse, and overdose as measured by national emergency department visit and overdose death rates from prescribed or greater-than-prescribed doses (FDA, 2021). In addition, other CNS depressants (e.g., barbiturates, antipsychot- ics, and neuroleptic drugs; antiepileptic and antiparkinsonian drugs; anesthetics; autonomic nervous system drugs; and muscle relaxants) contributed to deaths where opioids were also impli- cated (SureScripts, 2022b). Tapering of chronic opioid therapy (CDC, 2022A) Sometimes, clinicians must decide whether to decrease or dis- continue chronic opioid therapy. Many factors may contribute to this decision: patient request; lack of response; signs of sub- stance abuse disorder, overdose, or other serious adverse events; or early signs of overdose risk. Therefore, any tapering schedule must be patient-specific to minimize withdrawal symptoms while maintaining adequate pain management. A general recommendation is to begin with a 10% decrease of the initial dose per week. Some patients who have taken opioids for a long time may require slower tapers (e.g., 10% per month). Adjust the rate and duration of the taper based on the patient’s response. It is advisable to slow or pause a taper to manage with- drawal symptoms rather than reversing the taper. It is essential to discuss the risk of overdose if a patient quickly returns to a prescribed higher dose. Consider prescribing naloxone to reverse possible overdose symptoms. After achieving the smallest avail- able dose, the interval between opioid doses increases, and opi- oids stop when taken less than once a day. Naloxone for emergent opioid overdose On average, every eight minutes, an individual dies from an opi- oid overdose (Skolnick, 2018). Individuals at higher risk for acute overdose include those who use prescription opioids, benzodi- azepines, and alcohol, as well as individuals with substance or mental health use disorders. These factors affect the entire family since these individuals may obtain opioids from family members. Children are at risk when ingesting opioids in the home. Individu- als who have lower tolerance due to incarceration, detoxification, or other controlled settings are also at higher risk for acute opioid overdose. Physiological damage can occur after 4 minutes, and death occurs in 4 to 6 minutes. Signs and symptoms of acute opi- oid overdose include: ● Unusual sleepiness or unresponsiveness. ● Decreased or absent breathing. ● Slow heartbeat or low blood pressure. ● Skin feels cold and clammy. ● Pinpoint pupils. ● Dusky nails and lips. Naloxone hydrochloride is an opioid antagonist which blocks opi- ate receptors in the brain and other parts of the body (drugs.com,
Tori et al. (2020) found that alcohol and benzodiazepine coin- volvement in opioid-involved overdose deaths was common, var- ied by opioid subtype, and was associated with state-level binge drinking and benzodiazepine prescribing rates. The FDA states that clinicians should limit prescribing opioid pain medicines with benzodiazepines or other CNS depressants only to patients with inadequate alternative treatment options. Avoid prescribing opioid-containing cough medicines to patients taking benzodiaz- epines or other CNS depressants, including alcohol. When pre- scribing medications, limit dosages and the duration of each drug to the least possible while achieving the desired clinical effect. Counseling patients regarding possible adverse severe reactions is critical (FDA, 2021). The FDA clarified this warning for patients taking opioid-addic - tion medications. Specifically, the FDA advised that the opioid- addiction medications buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the CNS. Although the combined use of these drugs increases the risk of severe side effects, the harm caused by un- treated opioid addiction can outweigh these risks. These medi- cations are often used with counseling and behavioral therapies for patients undergoing MAT, and patients can be treated with them indefinitely. Careful patient monitoring is necessary when prescribing benzodiazepines or other CNS-depressant agents in combination with MAT and appropriate and continued patient counseling (FDA, 2022d). Patients at high risk of harm, such as pregnant women or those with substance abuse disorder, may require coordination with treatment experts. Withdrawal symptoms are especially concern- ing in pregnant patients due to the risks to the mother and fe- tus. It is crucial to ensure patients receive appropriate encour- agement and psychosocial support, including consultations with mental health providers and treatment for opioid use disorder as needed. Reassure patients that most people have improved func- tion, without worse pain, after tapering opioids. In addition, some patients experience less pain after a taper, even though the pain may worsen initially. Self-Assessment Quiz Question #5 Any tapering schedule must be patient-specific to minimize withdrawal symptoms. The CDC recommends what percentage 2023). By occupying the receptor and blocking the action of the opioid, effects of naloxone reverse opioid effects by competing for opioid sites in the central nervous system, with a great affinity for the µu receptor (drugs.com, 2023). Naloxone nasal inhalation kits are widely accepted for opioid reversal in emergent situations (Skolnick, 2018). The Substance Abuse and Mental Health Services Administra- tion (SAMHSA) oversees the accreditation and standards for opioid treatment programs (OTPs). Many medication-assisted treatment (MAT) medications in opioid addiction are regulated under the CSA (SAMHSA, 2022a). The Drug Addiction Treatment Act of 2000 (DATA 2000 Act) permits physicians who meet set qualifications to manage opioid dependency with FDA-approved medications, such as buprenorphine, in treatment settings other than OTPs (see Table 9). The DATA 2000 Act allows physicians to obtain a waiver (i.e., DEA-X) to treat opioid use disorder with Schedules III, IV, and V medications (such as buprenorphine alone or in combination) that the FDA has approved for this indication (SAMHSA, 2022b). while maintaining adequate pain management? a. 10% decrease of the initial dose per week. b. 15% decrease of the initial dose per week. c. 25% decrease of the initial dose per week. d. 45% decrease of the initial dose per week.
Page 75
Book Code: RPUS3024
EliteLearning.com/Pharmacy
Powered by FlippingBook