● The patient will agree to periodic drug testing (i.e., urine drug screening). ● The clinician is responsible for making themselves available or having a covering clinician available to care for unforeseen problems and to prescribe scheduled refills. (HHS, 2019a) Complete pain relief is often not achieved; a 30% reduction in pain is considered a good clinical response (Dowell et al., 2016). In a function-based treatment strategy for chronic pain, treatment efficacy is measured by the patient’s ability to achieve improved function rather than complete pain relief. These goals may include going to work, walking, achieving enhanced sleep, or improving social interactions. It may be beneficial to begin with more easily achievable goals and progress to more challenging ones after initial successes. This approach can be much more motivating than a plan resulting in early treatment failure (HHS, 2019b). depression and other mental health disorders place patients at increased risk for misuse and abuse of opioid analgesics, including addiction and overdose. In addition, untreated depression may interfere with pain resolution. In cases where the opioid dosage increases, the prescriber should educate the patient on the risk of cognitive impairment that can negatively impact their ability to drive or perform other activities. Evidence-Based Practice: Is exercise effective in treating long-lasting low back pain? Long-lasting (chronic) low back pain is a common cause of disability worldwide and is expensive in terms of healthcare costs and lost working hours. Exercise therapy aims to increase muscle and joint strength, improve muscle function and range of motion, reduce pain and disability, speed recovery, and return the patient to their usual activities. Examples of exercise therapies include general physical fitness programs delivered in a group setting, aerobic exercise in the form of walking programs, and strengthening specific muscles or groups of muscles to increase core stability. Hayden et al. (2021) conducted a systematic review. They found moderate-certainty evidence that exercise treatment is more effective than no treatment, usual care, or placebo for pain intensity and functional limitations outcomes. That is, exercise may be more effective for pain and is probably more effective for disability than common treatments in the short and medium term. a dose increase. Instruct patients to swallow ER/LA opioid analgesics to avoid exposure to/ingestion of a potentially fatal dose. ● Accidental ingestion of ER/LA opioid analgesics can result in a fatal overdose, especially in children. (Note: Accidental pet ingestion has also led to a deadly dose.) ● Prolonged ER/LA opioid analgesics use during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated. In prolonged opioid use in pregnant women, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure appropriate treatment will be available. ● Initiation of CYP 3A4 inhibitors (or discontinuation of medications that induce CYP 3A4) can result in a fatal overdose.
Chronic pain treatment agreements that outline the responsibilities of the patient and the provider are indicated for long- term treatment with opioids or other medications with the potential for substance abuse disorder. The U.S. Department of Health and Human Services, Division of Indian Health Services, recommends that treatment agreements include the following tenets: ● Treatment goals are defined in terms of pain management, restoration of function, and safety. ● The patient is responsible for safe medication use (i.e., not taking more than prescribed; understanding the dangers of using in combination with alcohol, cannabis, benzodiazepines, or other CNS depressants unless closely monitored by the prescriber). ● The patient will ensure secure storage and safe disposal. ● The patient will obtain opioids from only one clinician or practice. ● The patient will fill the opioids at only one pharmacy. Initiating opioid therapy for chronic noncancer pain When initiating opioid therapy for chronic pain, clinicians should start with immediate-release opioids and avoid extended- release formulations or long-acting opioids. Begin with the lowest effective dosage. Evaluate patients within one to four weeks of starting opioid therapy or dose escalation. Clinicians should evaluate patients every three months to assess the continued benefit and the development of any adverse effects once the opioid dose is stabilized. If the patient no longer benefits from the opioid therapy, the clinician should optimize the treatment regimen, including adding other treatment modalities or tapering off the opioid regimen (CDC, 2022b). Some patient populations and patients with certain conditions require closer monitoring and counseling before initiation and during chronic pain treatment. For example, patients receiving other central nervous system depressants, especially benzodiazepines, require special attention because of an increased risk of adverse events, including increased sedation, confusion, difficulty driving or performing other tasks requiring high concentration levels, respiratory depression, and overdose. It is also necessary to assess how the patient uses work equipment that requires precise motor control, heavy machinery, or chemical or biohazardous materials. Pregnant women also require an enhanced level of caution because chronic opioid use during pregnancy increases the risk of harm to the newborn, specifically neonatal opioid withdrawal syndrome. Further, these medications must be used cautiously in breastfeeding women because some opioids can be transferred to breast milk and may cause sedation or respiratory depression in the nursing infant. In elderly patients, clinicians should consider employing a lower starting dose, a slower titration period, and a longer dosing interval with more frequent monitoring. Patients with psychiatric disorders are at increased risk of adverse events associated with chronic opioid therapy. Untreated
Special considerations for extended-release and long-acting (ER/LA) opioids The FDA advises that extended-release and long-acting (ER/ LA) opioid analgesics be reserved for patients when alternative treatment options are ineffective, not tolerated, or inadequate to provide sufficient pain relief (FDA, 2018). Before prescribing these products, review FDA-approved REMS programs,
medication guides, and black box warnings (BBW) (FDA, 2021). These products, listed in Table 7, are not for acute pain, pain that is mild or not expected to persist for an extended period, or use on an as-needed basis. In addition, the FDA-approved BBWs on these products advise clinicians of the following: ● ER/LA opioid analgesics expose users to addiction, abuse, and misuse risks, leading to overdose and death. Assess each patient’s risk before prescribing and regularly monitor the development of these behaviors and conditions. ● Life-threatening severe or fatal respiratory depression may occur. Monitor closely, primarily upon initiation or following
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