Neck Pain in Adults _________________________________________________________________________
IDENTIFYING ADDICTION IN PATIENTS PRESCRIBED OPIOIDS When implementing a neck pain treatment plan that involves the use of opioids, the patient should be frequently reassessed for changes in pain origin, health, and function. Signs and symptoms that, if present, may suggest a problematic response to the opioid and interference with the goal of functional improvement include: • Excessive sleeping or days and nights turned around • Diminished appetite • Short attention span or inability to concentrate • Mood volatility, especially irritability • Lack of involvement with others • Impaired functioning due to drug effects • Use of the opioid to regress instead of re-engaging in life • Lack of attention to hygiene and appearance Information obtained by patient history, physical examination, and interview, from family members, a spouse, or state prescription drug monitoring database, and from the use of screening and assessment tools can help the clinician to stratify the patient according to level of risk for developing problematic opioid behavioral responses. A urine drug test should be performed prior to initiating opioid treatment. Low-risk patients receive the standard level of monitoring, vigilance, and care. Moderate-risk patients should be considered for an additional level of monitoring and provider contact, and high-risk patients are likely to require intensive and structured monitoring and follow-up contact, additional consultation with psychiatric and addiction medicine specialists, and limited supplies of short-acting opioid formulations. If substance abuse is active, in remission, or in the patient’s history, one should consult an addiction specialist before starting opioids. In the setting of active substance abuse, opioids should not be prescribed until the patient is engaged in treatment/ recovery program or other arrangement made, such as addiction professional co-management and additional monitoring. When considering an opioid analgesic (particularly those that are extended-release or long-acting), one must always weigh the benefits against the risks of overdose, abuse, addiction, physical dependence and tolerance, adverse drug interactions, and accidental exposure by children. Screening and assessment tools can help guide patient stratification according to risk level and inform the appropriate degree of structure and monitoring in the treatment plan. It should be noted that despite widespread endorsement of screening tool use to help determine patient risk level, most tools have not been extensively evaluated, validated, or compared to each other. Source: [177; 178; 179; 180; 181; 182] Table 5
Oxycodone/Naloxone To reduce opioid-induced constipation during long-term therapy, the opioid antagonist naloxone was combined with oxycodone extended-release in a fixed-dose 2:1 ratio. Unlike short-acting naloxone, the extended-release formulation limits systemic exposure and does not block or reverse oxycodone analgesia [183]. Combination oxycodone/naloxone (Targin) was FDA-approved in 2014 but has since been discontinued for use in the United States [173; 184; 185]. Oxycodone/ naloxone and oxycodone extended-release show similar efficacy in chronic pain. Oxycodone/naloxone reduces but does not eliminate constipation and seems more effective in new patients with opioid-induced constipation than in preventing constipation during treatment [183]. Buprenorphine Buprenorphine differs from standard opioids as a partial mu-opioid receptor agonist. This produces a respiratory depression ceiling effect, making buprenorphine safer in overdose, and a euphoria ceiling effect that lowers drug “liking.” Buprenorphine is a kappa-opioid receptor antagonist, producing an anti-hyperalgesic effect relevant to neuropathic pain that often contributes to chronic spine-related pain
[186; 187; 188]. Transdermal buprenorphine is the primary form used in chronic pain treatment. The transdermal patch is effective for seven days, after which it is replaced [189]. A buccal formulation was FDA-approved in 2016 based on studies demonstrating efficacy in patients with moderate-to- severe chronic low back pain [190]. The buccal formulation is available in a wider range of doses compared with the transdermal patch and can be administered every 12 hours [191]. The lower abuse potential of transdermal buprenorphine also reflects its slow onset rate and difficulty extracting buprenorphine from the patch. Compared with fentanyl patches, extended-release opioids, and extended-release tramadol, transdermal buprenorphine has shown the lowest rates of abuse and diversion. Common side effects are constipation, dry mouth, nausea, vomiting, headache, dizziness, somnolence, and application site skin irritations [186; 187; 189]. In a study of transdermal buprenorphine therapy of 465 patients (median age: 67 years) with diverse chronic pain conditions, transdermal buprenorphine pain relief was rated effective/very effective by 69% after 3 months and 91% after
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