_______________________________ Prescription Opioids and Pain Management: The Tennessee Guidelines
be assessed on follow-up. A commonly used assessment tool is the three-item PEG assessment scale [94]: • P ain average
The need for frequent progress and benefit/risk assessments during the trial should be included in patient education. Patients should also have full knowledge of the warning signs and symptoms of respiratory depression. The risk of overdose deaths starts at 40 mg MEDD in opioid-naïve patients, and the highest risk is in the first two weeks of therapy [94]. Prescribers should carefully reassess evidence of benefits and risks when increasing the dosage to ≥50 mg MEDD. Decisions to titrate dose to ≥90 mg MEDD per day should be avoided or carefully justified [10]. CONCURRENT USE OF BENZODIAZEPINES AND OTHER CONTROLLED SUBSTANCES Benzodiazepines In 2018, 33% of persons who died of an opioid overdose also tested positive for benzodiazepines, a class of sedative medication commonly prescribed for anxiety, insomnia, panic attack, and muscle spasm [95]. Benzodiazepines work by raising the level of the neurotransmitter GABA in the brain. Common formulations include diazepam (Valium), alprazolam (Xanex), and clonazepam (Klonopin). Combining benzodiazepines with opioids is unsafe because both classes of drug cause central nervous system (CNS) depression, sedation, and can decrease respiratory drive—the usual cause of overdose fatality. Both classes have the potential for drug dependence and addiction. Both the CDC and the Tennessee Department of Health recommend that healthcare providers avoid prescribing benzodiazepines concurrently with opioids whenever possible [10; 94]. If a benzodiazepine is to be discontinued, the clinician should taper the medication gradually, because abrupt withdrawal can lead to rebound anxiety and complications such as hallucinations, seizures, delirium tremens, and, in rare instances, death. A commonly used tapering schedule is a reduction of the benzodiazepine dose by 25% every one to two weeks [10]. The Tennessee Sample Informed Consent/ Controlled Substance Agreement includes patient education on benzodiazepine activity, side effects, potential for physical dependency, and withdrawal symptoms [94]. Carisoprodol Barbiturates, muscle relaxants, and hypnotics also have sedative side effects that can potentiate respiratory depression in patients taking opioids. Providers should consider whether benefits outweigh risks of concurrent use of these drugs before prescribing opioids. Of particular concern is carisoprodol (Soma), a noncontrolled, central-acting skeletal muscle relaxant whose active metabolite is meprobamate, with which it shares significant sedative effects and abuse potential [96]. Clinicians should check the Tennessee CSMD for concurrently prescribed controlled medications and should consider consultation with pharmacists and pain specialists as part of the management plan when opioids are co-prescribed with other CNS depressants [10].
• Interference with E njoyment of life • Interference with G eneral activity
In opioid-naïve patients, one should start at the lowest possible dose and titrate to effect. Morphine is considered the standard for treatment of moderate to severe pain and is used as the reference point for safe dosing with other approved opioids. Morphine equivalent daily dose (MEDD) is the equipotent dose of any opioid in reference to morphine. The likelihood of adverse effects increases as the MEDD increases, therefore identifying at-risk patients is an essential step in assuring patient safety. Data-informed guidance suggests that overdose death risk starts at 40 MEDD in opioid-naïve patients; the risk increases tenfold above 81 MEDD for all patients [94]. Additional information is available in the Tennessee guidelines and a chart of conversion factors for use in clinical practice can be found at the Tennessee CSMD website. Dosages for opioid-tolerant patients should always be individualized and titrated by efficacy and tolerability [1; 10]. When initiating opioid therapy for chronic pain, clinicians should select an immediate-release, short-acting opioid instead of an extended-release/long-acting opioid formulation [10; 94]. Additional principles, emphasized by the Tennessee Practice Guidelines, include [94]: • Any product containing buprenorphine, whether with or without naloxone, may only be prescribed for a use recognized by the FDA. • Benzodiazepines should be generally avoided in combination with chronic opioid therapy. When opioids are selected for treatment of chronic pain in a patient taking benzodiazepines for mental health purposes, the provider should make all reasonable efforts to consult with a mental health professional to assess the necessity of benzodiazepine medication. • Any product containing buprenorphine, with
or without naloxone, may only be prescribed for a use recognized by the U.S. Food and Drug Administration, in accordance with statute.
• Methadone is primarily intended for use in treating addiction and should only be prescribed for chronic pain by providers who understand the complexities of methadone use and have taken all reasonable steps to refer the patient to a pain specialist. The decision to treat pain with methadone should be made only after considering all available treatment options. • Whenever treatment deviates from recommended guidelines, the reason should be documented in the medical record.
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