Responsibilities and Requirements of Prescribing Schedule II Opioid Drugs _ ___________________________
CHRONIC PAIN If opioids are used, they should be combined with nonphar- macologic therapy and non-opioid pharmacologic therapy, as appropriate. Clinicians should consider opioid therapy only if expected benefits for pain and function are anticipated to outweigh risks to the patient [10]. Opioid therapy for chronic pain should be presented as a trial for a pre-defined period (e.g., ≤30 days). The goals of treatment should be established with all patients prior to the initiation of opioid therapy, including reasonable improvements in pain, function, depression, anxiety, and avoidance of unnecessary or excessive medication use [1; 10]. The treatment plan should describe therapy selection, measures of progress, and other diagnostic evaluations, consultations, referrals, and therapies. The need for frequent progress and benefit/risk assessments during the trial should be included in patient education. Patients should also have full knowledge of the warning signs and symptoms of respiratory depression. Prescribers should carefully reassess evidence of benefits and risks when increas- ing the dosage to ≥50 mg morphine equivalent dose (MED) per day. Decisions to titrate dose to ≥90 mg MED/day should be avoided or carefully justified [10; 40]. Prescribers should be knowledgeable of federal and state opioid prescribing regulations. Issues of equianalgesic dosing, close patient monitoring during all dose changes, and cross- tolerance with opioid conversion should be considered. If necessary, treatment may be augmented, with preference for nonopioids and immediate-release opioids over long-acting/ extended-release opioids. Taper opioid dose when no longer needed [16]. CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK Information obtained by patient history, physical examina- tion, and interview, from family members, a spouse, or state prescription drug monitoring program (PDMP), 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 ( Table 1) [17; 28]. Low-risk patients receive the standard level of monitoring, vigi- lance, 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 [10; 26].
PAIN MANAGEMENT APPROACHES IN DENTISTRY
Dental professionals should know the best clinical practices in opioid prescribing, including the associated risks of opioids, approaches to the assessment of pain and function, and pain management modalities. Pharmacologic and nonpharma- cologic approaches should be used on the basis of current knowledge in the evidence base or best clinical practices. Patients with moderate-to-severe chronic pain who have been assessed and treated, over a period of time, with non-opioid therapy or nonpharmacologic pain therapy without adequate pain relief, are considered to be candidates for a trial of opioid therapy [9; 10]. Initial treatment should always be considered individually determined and as a trial of therapy, not a defini- tive course of treatment [11]. In 2022, the CDC published an updated guideline for the prescription of opioids to manage all types of pain [34]. The updated clinical practice guideline is intended to achieve improved communication between clinicians and patients about the risks and benefits of pain treatment, including opioid therapy for pain; improved safety and effectiveness for pain treatment, resulting in improved function and quality of life for patients experiencing pain; and a reduction in the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death [34]. It is important to remember that inappropriately limiting necessary opioid medications to address patients’ pain can be damaging and should be avoided. ACUTE PAIN Long-term opioid use often begins with treatment of acute pain. Many acute pain conditions can be managed most effec- tively with nonopioid medications. Nonsteroidal anti-inflam- matory drugs (NSAIDs) have been found to be more effective than opioids for surgical dental pain, and the American Dental Association recommends NSAIDs as first-line treatment for acute dental pain management [5]. When opioids are used for acute pain, dentists should prescribe the lowest effective dose of immediate-release opioids in a quan- tity no greater than that needed for the expected duration of severe pain. In most cases, three days or less will be sufficient; more than seven days will rarely be needed [10]. However, it is important to note that this guideline is based on emergency department prescribing guidelines for non-traumatic non- surgical pain [12]. It may be necessary to prescribe for longer periods in patients with acute severe pain. With postoperative, acute, or intermittent pain, analgesia often requires frequent titration, and the two- to four-hour analgesic duration with short-acting hydrocodone, morphine, and oxy- codone is more effective than extended-release formulations. Short-acting opioids are also recommended in patients who are medically unstable or with highly variable pain intensity [13; 14; 15].
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