Patients should be referred to a psychiatrist or mental health specialist when under treatment for a co-occurring mental health disorder. Addiction specialists can assist in the treatment of patients who have chronic pain and a history of addiction. Opioid treatment programs are available for patients with opioid addiction. 118 When referring a patient to a specialist, communicate with the specialist before the patient’s first visit both verbally and with a formal referral letter to ensure continued coordination of care. Consider the affordability and insurance accepted by the recommended practice if the patient is to be compliant. It is important to encourage the patient to follow through and attend specialist appointments. 118 Safely Halting Opioid Therapy If at any point benefits no longer outweigh the potential risks of continuing opioid therapy, opioid dosages should be tapered down or discontinued. Opioid withdrawal symptoms can be
very unpleasant but are generally not life-threatening. Weaning can be done in a number of ways, ranging from a slow 10% dose reduction per week to a more rapid 25% to 50% reduction every few days. The rate of reduction should be patient-specific and can depend on the reasoning behind discontinuing opioid therapy, medical or psychiatric comorbidities, and current dose. For example, a patient experiencing an adverse reaction may require faster tapering than others. Practitioners should consider referring patients to addiction medicine specialists when tapering is required due to aberrant behavior. 118 If it is necessary to terminate the provider/patient relationship, clinicians must give adequate notice, support the transition by making records and discussion available to the new provider, and provide coverage for emergency treatment during the transition period. If care is discontinued without reasoning or provision for continued care, providers can be held accountable for patient abandonment. 166
Case Study 5 Part 2 After a slight dose adjustment of the gabapentin and six months of opioid therapy, Mr. Davidson reports continued functional progress and acceptable levels of pain. He has increased his level of physical activity and reports that his mood and general health are better as a result. He says he would like to try to taper down his use of the opioid. Which of the following tapering plans would be most appropriate for Mr. Davidson to use to discontinue his opioids? a. Tapering should not be done because his pain is under control b. His opioids should be stopped without tapering c. He should consider a reduction of 20% per week d. He should consider a rapid taper with a goal to discontinue within one week Answer: C. Since the patient states he is ready to try reducing his opioid dose, it should be attempted gradually so his pain does not rebound back and negatively impact his progress. Appropriate assessment and action: This is a treatment success; the healthcare team should be gratified. In this case, Mr. Davidson is given clear and specific instructions on how to taper his opioid dosage to the lowest effective dosage level. Safe Storage and Disposal of Opioids
A variety of approaches are available for home disposal of unused medications. The FDA recommends removing the drugs from their original containers and mixing them with unappealing substances, such as used coffee grounds or cat litter. Such mixes should then be sealed in a plastic bag or sealable container before placing them in the garbage. Pills should not be crushed, and never flushed down a drain or toilet, due to theoretical risks of medications polluting the water supply. 168 Many communities sponsor take-back days for unused medications. The U.S. Drug Enforcement Agency (DEA) regularly sponsors such programs, and many communities have their own programs. Local law enforcement officials can provide information on the availability of local take-back programs or disposal sites. 168 Opioid Patient Education Thorough patient education about the safe use, storage, and disposal of opioid medications is an essential component of opioid prescribing best practices. This education can be partially integrated into standard patient-provider agreements or informed consent documents. As with other patient-directed
It is well established that many prescription drug abusers obtain them from family and friends; more than 70% of people taking opioids for nonmedical reasons obtain them from friends or family. 167 Therefore, appropriate medication disposal is an effective strategy in preventing potential abuse. Before receiving opioids, patients should be informed of these facts and provided key steps for safely maintaining their medications, including information regarding take-back programs for unneeded medications. 168 If possible, opioid pain medications should be stored in a locked cabinet or another secure storage unit. Storage areas should be cool, dry, and out of direct sunlight. Remind patients not to store medications in their car, to keep medications in the original containers, and to avoid storing medications in the refrigerator or freezer unless specifically directed to do so by a healthcare provider or pharmacist. Medications should always be stored out of the reach of children and pets. 167
Book Code: CA23CME
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