to breast milk and may cause sedation or respiratory depression in the nursing infant. In elderly patients, clinicians should consider employing a lower starting dose, a slower titration period, and a longer dosing interval with more frequent monitoring. Patients with psychiatric disorders are at increased risk of ad- verse events associated with chronic opioid therapy. Untreated depression and other mental health disorders place patients at in- creased risk for misuse and abuse of opioid analgesics, including addiction and overdose. In addition, untreated depression may interfere with pain resolution. In cases where the opioid dosage increases, the prescriber should educate the patient on the risk of cognitive impairment that can negatively impact their ability to drive or perform other activities.
Evidence-Based Practice: Is exercise effective in treating long-lasting low back pain? Long-lasting (chronic) low back pain is a common cause of disability worldwide and is expensive in terms of health- care costs and lost working hours. Exercise therapy aims to increase muscle and joint strength, improve muscle func- tion and range of motion, reduce pain and disability, speed recovery, and return the patient to their usual activities. Examples of exercise therapies include general physical fit - ness programs delivered in a group setting, aerobic exercise in the form of walking programs, and strengthening specific muscles or groups of muscles to increase core stability. Hayden et al. (2021) conducted a systematic review. They found moderate-certainty evidence that exercise treatment is more effective than no treatment, usual care, or placebo for pain intensity and functional limitations outcomes. That is, exercise may be more effective for pain and is probably more effective for disability than common treatments in the short and medium term. dose increase. Instruct patients to swallow ER/LA opioid an- algesics to avoid exposure to/ingestion of a potentially fatal dose. ● Accidental ingestion of ER/LA opioid analgesics can result in a fatal overdose, especially in children. (Note: Accidental pet ingestion has also led to a deadly dose.) ● Prolonged ER/LA opioid analgesics use during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated. In prolonged opioid use in pregnant women, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure appropri- ate treatment will be available. ● Initiation of CYP 3A4 inhibitors (or discontinuation of medica- tions that induce CYP 3A4) can result in a fatal overdose.
Special considerations for extended-release and long-acting (ER/LA) opioids The FDA advises that extended-release and long-acting (ER/ LA) opioid analgesics be reserved for patients when alternative treatment options are ineffective, not tolerated, or inadequate to provide sufficient pain relief (FDA, 2018). Before prescribing these products, review FDA-approved REMS programs,
medication guides, and black box warnings (BBW) (FDA, 2021). These products, listed in Table 7, are not for acute pain, pain that is mild or not expected to persist for an extended period, or use on an as-needed basis. In addition, the FDA-approved BBWs on these products advise clinicians of the following: ● ER/LA opioid analgesics expose users to addiction, abuse, and misuse risks, leading to overdose and death. Assess each patient’s risk before prescribing and regularly monitor the de- velopment of these behaviors and conditions. ● Life-threatening severe or fatal respiratory depression may oc- cur. Monitor closely, primarily upon initiation or following a Table 7: Common Opioids for Chronic Pain Management
Available Oral Strengths
Medication
Dosage
Clinical Considerations
Hydrocodone, extend- ed-release tablets • Zohydro ER
Tablets: • 10 mg • 15 mg • 20 mg • 30 mg • 40 mg • 50 mg
Initiate: • 10 mg every 12 hours. • Titrate by 10 mg every 12 hours as needed every 7 to 10 days.
The conversion factor for daily oral opioids to Zohydro: • Hydrocodone: 1
• Oxycodone: 1 • Methadone: 1 • Oxymorphone: 2 • Hydromorphone: 2.67 • Morphine: 0.67 • Codeine: 0.1
Do not use it to convert Zohydro to other opi- oids, as it will result in overestimation and pos- sible fatal overdose. During treatment with extended- release for- mulations, immediate- release formulations may be required for breakthrough pain.
EliteLearning.com/Pharmacy
Book Code: RPUS3024
Page 119
Powered by FlippingBook