Initial doses should be 25-50% lower than in those who are younger. 86 The VA/DoD practice guideline suggests that tramadol has benefits in older patients because of its partial mu agonist activity and demonstrated safety profile when combined with ACET, though drug-drug interactions should be evaluated when prescribing tramadol. 23 Children and Adolescents Evaluating the origin of the pain condition is important in the pediatric age group. If pain is not controlled, children are at risk for persistent pain as they grow to adulthood. 3 Use of multidisciplinary treatments is advised as is treatment of psychological conditions to manage difficulty coping, anxiety, and depression. It has been suggested that opioid analgesia may be indicated for certain chronic pediatric conditions; however, current guidelines generally exclude this population from treatment recommendations, and scientific investigation is scant into the indications and safety concerns with opioids for the pediatric population. 87 Accidental exposure to and ingestion of opioids can result in death. People with Renal and Hepatic Impairment Extra caution and increased monitoring is necessary when initiating and titrating opioid doses in people with renal and hepatic impairment. 64 In patients with renal compromise, accumulation resulting in toxicity has been observed in case studies; therefore, it is advised to monitor for opioid toxicity and to use non-opioids when possible. 88 People with Sickle Cell Disease Sickle cell disease affects approximately 100,000 people in the United States and is characterized by complex acute and chronic pain symptoms. 1
The disease is particularly prevalent among African Americans. According to the HHS Inter-Agency Task Force on best pain management practices, unpredictable, episodic exacerbations of acute pain pose a challenge to patients with sickle cell disease, and this pain generally has not responded to non- opioids prior to presentation. 3 Limited access to oral opioids at home for the treatment of unplanned acute pain can result in increased use of healthcare services that could have been avoided. Stigma, negative practitioner attitudes, and perceived racial bias may further complicate care. Effective models of pain treatment for patients with sickle cell disease include multidisciplinary teams of practitioners with experience treating the disease. Racial and Ethnic Disparities in Pain Care Evidence documents disparities in health care in racial and ethnic minority populations, often related to such factors as lack of insurance or primary care access, discrimination, environmental barriers to self-management, lower likelihood of being screened for or receiving pain treatment and more. 3,23 The disparities extend to mental health care and addiction treatment where access to care is very limited for Black individuals, Indigenous individuals, and other individuals of color. There is evidence that racial and ethnic minority populations prefer seeking treatment in primary care over specialty mental health settings. 89 Active Duty Military, Reserve Service Members, and Veterans Pain management in veterans and active military members can be complex. Combat- related injuries include ballistic wounds, burns, over-pressurization, and blunt trauma. 3
In addition, complications can arise from PTSD and traumatic brain injury. 3 Delaying pain treatment can lead to acute pain becoming chronic. 90 Veterans are also at risk for death by suicide, a risk compounded when pain conditions are present. HCPS can discuss suicide risk with service members and veterans and address pain treatment as part of suicide prevention as a recognized public health approach. 3 Medical Complexities of Pain Care Genetic and phenotypic variations influence how quickly or well different people metabolize opioids and other drugs. 74 Medical conditions, including kidney and liver disease, also cause variations in opioid metabolism. 74 The FDA has approved some tests, for example, one aimed at determining whether a patient is a CYP2D6 ultra- rapid metabolizer. 76 However, little data actually exist to inform the practice of pain management, and these tests are not routinely performed. 91 HPCs should be aware that genetics is one of many factors that may affect drug metabolism and responses, so patient experience with certain pain treatments or medications should be used to develop individualized treatment plans. Definitions Related to Opioid Use and Misuse The HHS Inter-Agency Task Force on best pain management practices endorsed a set of definitions to guide conversations and understanding of frequent terms related to opioid use and misuse. 3 These definitions are shown in Table 3. Diversion Most people who misuse prescription opioids are given them freely by friends or family members, though some people buy or steal them. 93
Table 3. Definitions Related to Opioid Use and Misuse 3
Term
Definition
Physical dependence
• Not the same as addiction • Occurs because of physiological adaptations to chronic exposure to opioids
• Withdrawal symptoms occur when medicine or opioid is suddenly reduced or stopped or when antagonist is administered • Symptoms can be mild or severe and can usually be managed medically or avoided through slow opioid taper
Tolerance
• Same dose of opioid given repeatedly produces reduced biological response • Higher dose of opioid is necessary to achieve initial level of response • Taking medication in a manner or dose other than as prescribed • Taking someone else’s prescription, even if for a medical complaint like pain
Misuse
• Taking medication to feel euphoria (i.e., to get high) • Nonmedical use of prescription drugs refers to misuse
Addiction
• Primary, chronic medical disease of brain reward, motivation, memory, and related circuitry • Dysfunction in circuits leads to characteristic biological, psychological, social, and spiritual manifestations as individual pathologically pursues reward and/or relief by substance use and other behaviors • Characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and dysfunctional emotional response • Involves cycles of relapse and remission • Without treatment or recovery activities, is progressive and results in disability or premature death
Opioid-use disorder • A problematic pattern of opioid use leading to clinically significant impairment or distress • Defined by 11 criteria in the DSM-5* over a 12-month period • Previously classified as “opioid abuse” or “opioid dependence” in DSM-4 • Severe opioid-use disorder also referred to as “opioid addiction” *DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition;92 diagnostic criteria given later in this activity
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