also noted to be related to spontaneous abortion, premature membrane rupture, preeclampsia, neonatal abstinence syndrome, and fetal death. More research is needed to better understand the association between certain opioids and congenital defects. Due to the risk of poor outcomes for mother and baby, opioid use in pregnant women should be assessed on a case by case basis. 162 . Driving and Work Safety Driving on opioid medications remains a controversial issue. Opioid medications may cause sleepiness, clouded thinking, decreased concentration, slower reflexes, or incoordination, all of which may pose a danger to the patient and others when driving or operating machinery; particularly at the initiation of therapy. On the other hand, several epidemiologic studies failed to show an association between long- term opioid use and motor vehicle accidents, fatalities, or citations for impaired driving. Since at least some of the cognitive and motor-impairing effects of Opioid Rotation Opioid rotation means switching from one opioid to another to better balance analgesia and side effects. Rotation may be needed because of the development of tolerance or lack of efficacy: bothersome or unacceptable side effects; increased dosing that exceeds the recommended limits of the current opioid (for example, dose limitations of co-compounded acetaminophen); or an inability to absorb the medication in its present form (for example, if there is a change in the patient’s ability to swallow, switch to a formulation that can be absorbed by a different route, such as transdermal). 165 The choice of which opioid to switch to should be patient-specific, based on prior experience, cost, availability, and other factors. The equianalgesic dose of the new drug can be calculated using an equianalgesic dose table. 165 An example, generated by Stanford University School of Medicine, is available at https://palliative.stanford.edu/opioid-conversion/ equivalency-table/. If switching to any opioid except methadone or fentanyl, the dose of the new medication should be reduced to 25 to 50% below the calculated equianalgesic dose to reduce the risk of adverse reactions. If switching to methadone, the dose should be reduced to 75 to 90% below the calculated Nonadherent Patients Patients who begin to exhibit aberrant drug-related behaviors or nonadherence to a prescription should be monitored more strictly than compliant patients. The management of chronic pain can be difficult. Putting a patient on the defensive can adversely impact their treatment. Patients presenting with complex or difficult-to-treat pain may require referral to a pain management specialist. Criteria for referral include: 119 ● Patients who continue to seek treatment for persistent, unexplained pain ● Patients with complex or high-risk pain treatment conditions, such as polypharmacy or those taking high-dose opioids
opioids resolve with steady use and a consistent dose, some activities or driving may be allowable at the discretion of the clinician and in the absence of signs of impairment. 164 All patients who are initially prescribed opioid medications, or those who have their dose increased, should be advised not to drive or engage in potentially dangerous work or other activities. There is no consensus on exactly how long they should abstain from driving. Patients should be educated about the increased risk of impairment when starting opioid therapy, when increasing doses, and when taking other drugs or substances that may exacerbate cognitive and motor impairment, such as alcohol or benzodiazepines. Clinicians should be aware that certain professions, such as pilots and school bus drivers, may have restrictions on the use of opioid medications. 164 equianalgesic dose, due to the complicated pharmacokinetics associated with methadone and the associated high risk of overdose. If switching to fentanyl, the equianalgesic dose found in the FDA- approved manufacturer’s labeling should be used. The choice of the upper or lower limit of dose reduction should be based on clinical judgment and patient characteristics. 165 Opioids can affect patients differently, so opioid rotation must be approached cautiously, especially when converting from short acting formulations to ER/LA products. As a result, an equivalent dose table must be used carefully since variations among charts and online calculator tools can potentially result in overdose. The best opioid dose for a specific patient must be determined through cautious titration and appropriate monitoring. In some cases, because of the potential risk of harm while switching between long term opioids, it may be wise to initially use lower doses of an ER/LA opioid than what might be suggested by equianalgesic charts and, at the same time, temporarily increasing the use of a short-acting opioid if needed. The LA opioid can be gradually increased to the point where the as-needed short-acting opioid is incrementally reduced until no longer necessary. 165 ● Patients with persistent pain with significant impacts on quality of life, function, or mental health that have not responded to initial treatment by a primary care provider ● Patients with persistent neuropathic pain who failed first-line therapies ● Patients who require multidisciplinary care, such as rehabilitation, mental health treatment, and medical management ● Patients who may be candidates for interventional treatment
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Book Code: CA23CME
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