Opioid Rotation A patient who suffers inadequate analgesia or intolerable side effects from one opioid may do better with a different opioid. 73 Because mu-agonists produce varied effects, switching a patient to a different medication may allow for pain control at a lowered dose. Care must be taken during the switch, because tolerance to a particular opioid does not translate to tolerance to another, a concept known as incomplete cross-tolerance. Patients should be monitored especially closely during any dose or formulation changes. Equianalgesic dosing tables, conversion charts, and calculators allow for the conversion of any opioid dose to the standard value of morphine (i.e., MME). 145 These tables have limitations because the supporting studies were conducted on single doses in patients with limited opioid exposure and did not report on dosing over time. 146 Therefore, experts have advised HCPs to use the equianalgesic dosing tables only as a starting point for opioid rotation, then reduce the dose (≥25% to 50% is advised, more with methadone) when converting to the new opioid. 77 A greater reduction is advised in patient who are older or medically frail. A 75% to 90% reduction 147 or considering the patient opioid naïve is advised for rotating to methadone followed by careful monitoring. 77 Conversions to transdermal routes of fentanyl and buprenorphine require special considerations, and HCPs should closely follow instructions in the prescribing information. Naloxone Prescription Naloxone can be used to save lives during overdose from a prescribed or illicit opioid, and its presence increases safety for the patient and others who live in or visit the home. 61 Strong evidence shows that providing naloxone to patients reduces opioid-related emergency-department visits. 93 Take-home naloxone can be easily prescribed and is generally recommended for all patients who receive an opioid prescription. It is particularly recommended with the presence of opioid overdose risk factors, such as history of overdose, history of SUD, clinical depression, opioid dosages ≥50 MME/day, concurrent benzodiazepine use, 61 or with evidence of increased risk by other measures. Two easily administered products are an auto-injection device and a nasal spray that requires no assembly. Patients given naloxone should keep it available at all times. 119 Naloxone administration can cause withdrawal symptoms, and people who have been administered it should have follow-up medical care. Laws vary by state regarding immunity for physicians or laypeople administering naloxone and can be checked here: http://www.pdaps.org/datasets/laws-regulating- administration-of-naloxone-1501695139. Patients and their caregivers and other family members should be instructed on the signs of overdose and counseled to do the following if an opioid overdose is suspected: 148 • Call 911 immediately • Administer naloxone if available
• Try to keep the person awake and breathing • Lay the person on their side to prevent choking • Stay with the person until emergency workers arrive Signs of an opioid overdose include: 76,148 • Small, constricted “pinpoint pupils” • Sedation or loss of consciousness • Slow, shallow breathing • Choking or gurgling sounds • Limp body • Pale, blue, or cold skin • Snoring heavily and cannot be awakened • Periods of ataxic (irregular) or other sleep- disordered breathing • Trouble breathing • Dizziness, confusion or heart palpitations Periodic Monitoring of Long-Term Opioid Therapy Follow-up with patients being treated with opioids is aimed at preventing potential misuse and tracking progress toward goals of pain control and function. Items to evaluate and document include analgesia, daily activities, adverse effects, aberrant drug- related behaviors, cognition, function, and quality of life. Similarly, patients should be reassessed for the development of tolerance and consideration of adjunctive therapies, opioid rotation, tapering, or discontinuation. 1 Tools available to assist with frequent reassessment and documentation include the Pain Assessment and Documentation Tool 149 and the COMM. 134 Ongoing periodic monitoring should incorporate checks of the PDMP and UDT. 137 When counseling patients, it is best to present UDT, PDMP data, and other monitoring measures to patients as a routine, consensual part of medical care using nonjudgmental language. The CDC guideline states that patients on opioid therapy should be reevaluated within one- to-four weeks of initiation or dosage change and at least every three months thereafter to ensure benefits outweigh risks. 61 Monitoring measures should be ongoing with every patient prescribed opioid therapy. 20 Patients with more comorbidities or higher misuse risk require more stringent monitoring measures and more frequent follow-up than patients with less risk for harm. 19 Some expert guidance recommends using risk stratification to set clinic visit frequency and other monitoring measures as determined by patient risk category (low, moderate, or high risk) during initial screening and clinical follow-up. 77 The recommended frequency for periodic review of PDMP data ranges from every prescription to every three months. 61 A consensus- based recommendation for UDT frequency is to test every patient at least once annually and higher-risk patients from two-to-three times annually. 137 It is very important to check local and state regulations and the recommendations of state medical boards in the area of practice, as many of these bodies set expectations for the timing and other particulars regarding UDT and PDMP checks.
Interpreting UDT results requires caution as the tests have limitations. 61 These include: 137 • Cross-reactivity with other drugs or substances • Potential for false positives (e.g., poppy seeds positive for opiates)
• Potential for false negatives • Variable drug metabolism • Laboratory error
Unexpected results, such as the absence of prescribed medications that could indicate diversion, should be discussed with the patient and documented in the record along with plans to address the results. Reassessment of any comorbid mental health disorders is also part of ongoing opioid therapy. Tools used for initial assessment of anxiety, depression, and somatic symptoms may also be used for monitoring of these conditions and reevaluating the treatment plan. 150 Seeking Expert Referrals Knowing hen to seek specialist care is part of treatment with opioids. In general, the HCP should consult with a pain, addiction, or mental-health specialist or refer the patient for specialist care whenever: • Pain continues to worsens with treatment • OUD is suspected or identified • Worsening of any mental health disorder is observed, including any SUD Uncontrolled or increasing pain severity despite attempts to optimize the medication regimen and in the absence of a clear explanation is a signal that pain specialist consultation or referral is advisable. In the presence of ongoing or severe behaviors suggestive of opioid misuse, HCPs should consider that patient may be suffering from OUD or other substance-use or mental-health disorders. When an active OUD or a recent OUD history is present, HCPs should strongly consider referral for medication treatment of addiction (unless this is provided in your clinic), specialist pain management, and/or tapering opioids and managing pain with non-opioid therapies. 61 Criteria of an OUD are described later in this activity. Signs and symptoms seen in a clinical scenario include: 151 • Taking opioids compulsively and long term for no legitimate medical purpose • If pain is present, taking opioids in excess of prescription • Obtaining opioids from unauthorized sources • Falsifying or exaggerating medical problems to receive opioids • Significant tolerance and physical dependence (although these may also occur in patients without OUD) • Conditioned responses of craving that persist after cessation
62
Powered by FlippingBook