Instructions: Spend 5 minutes reviewing the case below and considering the question that follows. Case Study 5 Part 1
Matt Davidson is a 69-year-old retired male high school physical education teacher. He has come to his primary care physician for his annual physical. He has a history of hypertension, osteoarthritis, and prostate cancer for which he was treated two years ago with a combination of external beam radiation and chemotherapy. His PSA is now near zero, and he has no signs of cancer, although he continues to be troubled by mild urinary incontinence and erectile dysfunction. On this visit, Mr. Davidson complains of joint pain, as well as a burning, tingling pain in his hands and feet. He states his pain started over 6 months ago. Last week, he had a tumble down the stairs and his pain got significantly worse. He asks if anything can be done for his symptoms. A full evaluation of the patient’s pain leads to a dual diagnosis of osteoarthritis and peripheral neuropathy secondary to chemotherapy. He rates his pain as a 7 or 8 on the 10-point scale, and reports disturbed sleep, which he says makes him more irritable during the day. He also says he no longer plays tennis, that walking has begun to hurt, and it is becoming difficult to use the computer keyboard. He takes ibuprofen several times a day but reports that this is not decreasing his pain and is giving him heartburn. He also states that he has tried taking acetaminophen around the clock as well as a topical lidocaine patch but it does not seem to be helping. 1. The provider is considering initiating an opioid for Mr. Davidson. Which of the following would be most appropriate? A. Short-acting oxycodone tablets B. Extended-release morphine tablets C. Fentanyl patch D. Buprenorphine tablets Answer: A. If an opioid is initiated, Mr. Davidson should receive an oral short-acting opioid agonist such as oxycodone. Long-acting opioids such as extended-release morphine and fentanyl patch should be reserved for patients with severe chronic pain. This will help minimize the risk of oversedation, respiratory depression, and overdose. Buprenorphine tablets are not recommended as first-line therapy for the treatment of pain; they are indicated for the treatment of opioid use disorder. Appropriate assessment and action: This information is used to create a treatment plan with the functional goals of: Reducing nighttime awakenings to no more than once per night; walking daily at least 1 mile without pain; and using the computer without pain. A return to tennis is left as a possible goal if less strenuous goals are achieved first. A low-dose oxycodone product is prescribed as needed for a week in conjunction with a prescription for gabapentin, as well as a prophylactic laxative (to counter the known opioid side effect of constipation). The patient receives printed information about the safe use, storage, and disposal of opioid medications.
Patients receiving more than 50MME per day should have their pain and function assessed more frequently, be considered for dose reductions if the benefits do not outweigh the risks, and be offered naloxone for overdose prevention. 156 Abuse-deterrent formulations Prescription drug abuse has spurred the development of novel drug formulations designed to resist various methods of tampering and misuse. Current technologies intend to make the product inactive unless taken as directed. For example, one class of deterrent formulation includes an opioid antagonist within the dosage form. If the dosage is crushed, the antagonist is released, rendering the opioid inactive. Thus, if such an ER/LA product was ground and inhaled, it would be inactive when inhaled. Another method is to use an inactive pro-drug formulation that is not activated unless subjected to gastric conditions. A third strategy is to change the physical structure of the dosage making it difficult or impossible to liquefy or concentrate the opioid. Abuse-deterrent opioid formulations, of course, do not prevent users from simply consuming too much of a medication or changing to a different opioid product. 157 A 2010 article described the impact of an abuse-deterrent formulation of the widely abused extended-release oxycodone product OxyContin. This new formulation was designed to change the physical structure of the tablet when crushed, making it difficult to inject or inhale the medication. A total of 103 patients with an addiction to prescription opioid medications were interviewed
to characterize the impact of this new formulation. The selection of OxyContin as a primary drug of abuse dropped from 35.6% to 12.8% of patients in a 21-month period. During the same period, the use of other high-potency opioids, such as fentanyl and hydromorphone, significantly increased from 20.1% to 32.3%. Interviewees had a unanimous preference for the older version of the product, and 24% devised a means to defeat the tamper- resistant properties. A total of 66% indicated that they changed to another opioid, with heroin being the most common. 158 Periodic Review and Monitoring If an opioid medication trial is deemed successful and opioid therapy is continued, periodic review and monitoring are recommended for the duration of treatment. Ensuring adherence to the prescribed treatment can be difficult, yet it is crucial to good outcomes. Opioid therapy is often complex and complicated by legal, social, pharmacologic, and psychological factors. Unless these issues can be overcome, safe and effective therapy may be impossible to achieve. 118,159 Within one to four weeks of starting opioid therapy for chronic pain, prescribers should assess the risks and benefits of continuing treatment or increasing the dosage, and risks and benefits should be continually assessed every three months or less. If at any point benefits no longer outweigh the potential risks of continuing therapy, other therapies should be re-evaluated, and opioid dosages should be tapered down or discontinued. 118
Before and periodically during opioid therapy, prescribers should reassess the risk factors for opioid-induced complications. Pain management plans should include strategies to mitigate risks such as offering naloxone to patients at a high risk of overdose, which includes patients taking more than 50 MME per day, patients with a history of overdose or substance use disorders, and those concurrently taking benzodiazepines. The patient’s history of controlled substance prescriptions should be evaluated periodically using prescription drug monitoring program (PDMP) data. Depending on the patient, data evaluation can range from every prescription to every three months. Urine drug testing can also be used as a tool to prevent the diversion of opioids; testing before and periodically during long-term opioid therapy is recommended by CDC. 118 Patients should be required to submit to urine drug screens before initiating opioid therapy and at least annually to confirm adherence to the treatment plan. Drug testing must be consensual as a part of the treatment plan, with the understanding that it is key to patient safety. 118 Opioid Side Effects Many patients treated with an opioid will experience side effects. Unfortunately, these side effects are challenging to manage, and tolerance to these problems frequently does not develop. Some patients can benefit from changing the opioid or the route of administration used. Proper screening, education, and pre-emptive treatment will minimize bad outcomes and enhance efficacy in many cases. 111
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