Elimination half-lives average 3 to 4 hours, offering a relatively narrow duration of action. As a result, they are best used for acute, intermittent, or breakthrough pain. 151 Single-agent immediate-release products are made using a variety of opioid agonists, including codeine, morphine, hydromorphone, and oxycodone. Combination products typically combine a nonopioid analgesic with an opioid, usually for use in patients with moderate pain, such as oxycodone or hydrocodone combined with acetaminophen. 152 In 2014, FDA recommended that prescribers discontinue the use of combination products containing more than 325 mg of acetaminophen per dosage unit. This decision was based on data suggesting that the increased risks of liver damage associated with larger doses of acetaminophen are not outweighed by any initial efficacy benefits. 153 Extended-release or long-acting opioid formulations are purposely engineered to control the release of a drug in such a way as to provide relatively consistent and prolonged drug levels in the blood. The onset of action is typically slower than that of immediate- release products but offers a much longer duration of action. These potent products are typically reserved
for patients suffering from chronic pain who have had previous exposure to opioids. 111,154 Initiating therapy Initial opioid treatment should be conducted as a trial to determine if the proposed regimen can safely and efficaciously treat your patient. An opioid trial should be pre-defined, and typically should be less than 30 days. It should only be conducted after treatment goals and a thorough treatment plan have been established. When initiating opioids, providers should: 118,155 ● Start at the lowest effective dose, and titrate up only if needed ● Initiate short-acting opioid formulations first ● Review the risks and benefits of therapy frequently, including with each dose increase ● Ensure the patient is aware of the signs of respiratory depression ● Taper doses down whenever possible ● Augment treatment with non-pharmacological and non-opioid therapy whenever possible A decision to continue opioid therapy after an appropriate trial should be based on whether there are clinically meaningful improvements in pain and function, and if these outweigh possible risks to patient safety. 118
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. 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.
Book Code: CA23CME
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