Dose titration Patients who are opioid-naïve or have modest previous opioid exposure should be started on a low dose of a short-acting opioid and titrated slowly upward to decrease the risk of opioid-related adverse effects. If it is unclear if a patient has recently been using opioids (either prescribed or non-prescribed), the clinician should assume that the patient is opioid-naïve (i.e., not tolerant) and proceed as if opioid-naïve. Because most patients who take opioids long term start with the treatment of acute pain, prescribers should ensure the lowest effective dose is used at the beginning of acute treatment. The quantity prescribed should be no more than what is needed for the duration of pain severe enough to require opioids. As a general rule, three days or less is often sufficient, and more than seven days of opioid treatment is rarely necessary for the treatment of acute pain. 118 Since higher dosages of opioids are associated with a higher risk of overdose and death, it is important to keep in mind the total daily dose to reduce the risk of poor outcomes. Calculating the total daily dose of opioids helps to identify patients who may require close monitoring or other measures to lower the risk of overdose. Using morphine milligram equivalents is a standardized method of calculating the total amount of opioids consumed in a day, regardless of which opioid the patient is taking. To calculate a patient’s total daily dose of opioids, one must first determine the total daily dose of each opioid the patient is prescribed. Next, convert to MME by multiplying the dose of each opioid by its conversion factor. Then, add the MMEs together to determine the total MME per day. The following conversion factors are used in the calculation of MME: 156 ● Codeine: 0.15 ● Fentanyl transdermal: 2.4 ● Hydrocodone: 1 ● Hydromorphone: 4 ● Methadone
50MME per day because of the lower effectiveness of high doses and the high risk of overdosage and death. Dosages of more than 90 MME per day should be avoided unless very carefully justified. 118 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 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
° 1-20mg/day: 4 ° 21-40mg/day: 8 ° 41-60mg/dal: 10 ° >/= 61-80mg/day: 12
● Morphine: 1 ● Oxycodone: 1.5 ● Oxymorphone: 3
Prescribers should carefully evaluate the risks and benefits of increasing opiate dosages to more than 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
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Book Code: CA23CME
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