Prescription Opioids and Pain Management: The Tennessee Guidelines _ ______________________________
RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS
Low Risk Definable physical pathology with objective signs and reliable symptoms Clinical correlation with diagnostic testing, including MRI, physical examination, and interventional diagnostic techniques With or without mild psychologic comorbidity With or without minor medical comorbidity No or well-defined and controlled personal or family history of alcoholism or substance abuse Age 45 years or older High levels of pain acceptance and active coping strategies High motivation and willingness to participate in multimodal therapy and attempting to function at normal levels Medium Risk Significant pain problems with objective signs and symptoms confirmed by radiologic evaluation, physical examination, or diagnostic interventions Moderate psychologic problems, well controlled by therapy Moderate coexisting medical disorders that are well controlled by medical therapy and are not affected by chronic opioid therapy (e.g., central sleep apnea) Develops mild tolerance but not hyperalgesia without physical dependence or addiction Past history of personal or family history of alcoholism or substance abuse Pain involving more than three regions of the body Defined pathology with moderate levels of pain acceptance and coping strategies Willing to participate in multimodal therapy, attempting to function in normal daily life High Risk Widespread pain without objective signs and symptoms Pain involving more than three regions of the body Aberrant drug-related behavior History of alcoholism or drug misuse, abuse, addiction, diversion, dependency, tolerance, or hyperalgesia
Major psychologic disorders Age younger than 45 years HIV-related pain High levels of pain exacerbation and low levels of coping strategies Unwilling to participate in multimodal therapy, not functioning close to a near normal lifestyle HIV = human immunodeficiency syndrome, MRI = magnetic resonance imaging. Source: [17]
Table 1
CO-PRESCRIBING NALOXONE According to CDC data for 2023, there were 105,007 deaths due to drug overdose nationwide, of which 79,358 resulted from a poisoning or overdose involving opioids, including more than 13,000 deaths involving a prescription opioid. Naloxone is a prescription opioid antagonist approved by the FDA for use in reversing the effects of an overdose involving opioids. The medication works by blocking opioid receptors to reverse suppression of respiratory drive caused by excessive opioid effect. Naloxone is available in multiple dosage and routes of administration, which include intramuscular, intravenous, and intranasal formulations [94].
In the outpatient setting, patients may be at risk for an overdose because of factors related to opioid dosage and usage, or because of pre-existing conditions that can negatively impact tolerance to opioids. Among patients to consider at risk are those who [94]: • Are taking greater than 50 MEDD per day • Are taking benzodiazepines • Reportedly use or have used heroin, illicit synthetic opioids, or misuse prescription opioids, or have a non-opioid substance use disorder or excessive alcohol use • Have a prior history of overdose • Have a respiratory condition (e.g., COPD, sleep apnea)
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MDTN1726
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