_______________________________ Prescription Opioids and Pain Management: The Tennessee Guidelines
CONSIDERATIONS FOR NON-ENGLISH- PROFICIENT PATIENTS
The decision to discontinue opioids carries the potential risk for troublesome withdrawal symptoms. Common symptoms of opioid withdrawal syndrome include nausea, vomiting, headache, abdominal pain, myalgia, and sweating. Although discomforting, the syndrome is usually not fatal, unlike benzodiazepine withdrawal. While low-dose and brief duration opioid regimens may not require weaning of the dosage, clinicians should always consider the need for a safely structured tapering protocol. Withdrawal may be managed by the prescribing physician or by referral to a pain or addiction specialist. The Tennessee Department of Health suggestions for a tapering protocol are [94]: • Upon decision to discontinue opioids, the prescribing physician has the responsibility to address the issue and take steps to minimize the impact of opioid withdrawal syndrome. • There are several different weaning protocols from various sources. A conservative approach recommends a 10% reduction in the original dose per week. Another is to reduce the dose by 25% every four days. The more rapid tapering protocols call for a daily 25% to 50% reduction off the previous day’s dose. (The Tennessee Department of Health does not recommend any one specific protocol.) • Among the several medications that are available for symptomatic relief, clonidine is effective in alleviating some symptoms of withdrawal syndrome. Clonidine can be administered 0.1–0.2 mg orally every six hours or with a transdermal patch at 0.1 mg/24 hours. Hypotension and anticholinergic side effects may be encountered. • Weaning opioids is not always indicated when they are to be discontinued. If recent UDT has shown that opioids are not present in the patient’s system, then a weaning protocol would not be necessary. • If drug diversion is suspected, then prescribing additional opioids is not indicated. In any circumstance in which prescribing additional opioids to a patient is thought to constitute more risk to the patient or to the community than the potential for withdrawal syndrome, no additional opioids should be prescribed. Patients should be reassured that opioid discontinuation is not the end of treatment; continuation of pain management will be undertaken with other modalities through direct care or referral. As a side note, cannabis use by chronic pain patients receiving opioid therapy has traditionally been viewed as a treatment agreement violation that is grounds for termination of opioid therapy. However, some now argue against cannabis use as a rationale for termination or substantial treatment and monitoring changes, especially considering the increasing legalization of medical use at the state level [48].
For patients who are not proficient in English, it is important that information regarding the risks associated with the use of opioids and available resources be provided in their native language, if possible. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required. Interpreters can be a valuable resource to help bridge the communication and cultural gap between patients and practitioners. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers who ultimately enhance the clinical encounter. In any case in which information regarding treatment options and medication/treatment measures are being provided, the use of an interpreter should be considered. Print materials are also available in many languages, and these should be offered whenever necessary. IDENTIFICATION OF DRUG DIVERSION/ SEEKING BEHAVIORS Research has more closely defined the location of prescribed opioid diversion into illicit use in the supply chain from the manufacturer to the distributor, retailer, and the end user (the pain patient). This information carries with it substantial public policy and regulatory implications. The 2015 National Survey on Drug Use and Health asked non-medical users of prescription opioids how they obtained their most recently used drugs [51]. Among persons 12 years of age or older, 40.5% obtained their prescription opioids from a friend or relative for free, 34.0% got them through a prescription from one doctor (vs. 17.3% in 2009–2010), 9.4% bought them from a friend or relative, and 3.8% took them from a friend or relative without asking [51]. Less frequent sources included a drug dealer or other stranger (4.9%); multiple doctors (1.7%); and theft from a doctor’s office, clinic, hospital, or pharmacy (0.7%) (vs. 0.2% in 2009–2010) [51]. As discussed, UDTs can give insight into patients who are misusing opioids. A random sample of UDT 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 [52]. Negative UDT 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 aberrant UDT results and that a negative result for the prescribed opioid or a positive UDT may serve as the pretense to terminate a patient rather than guide him/her into addiction treatment or an alternative pain management program [53].
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