Prescribe opioids with caution for patients at high risk of addiction. There are two major risk factors for opioid addiction:
current or past history of alcohol or substance use disorder
current or past history of a psychiatric disorder( including anxiety, depression, and post-traumatic stress disorder)
Do not prescribe potent opioids for high-risk patients unless they have a pain condition that interferes with daily life and has not responded to a full trial of all major pain treatments( e. g., nonsteroidal antiinflammatory agents, antidepressants, anticonvulsants, physiotherapy and other nonpharmacologic therapies). In cases where opioids are to be prescribed for high-risk patients, avoid hydromorphone, fentanyl, and oxycodone; dispense small quantities at frequent intervals( rather than larger amounts at extended intervals); order regular urine drug screens to identify use of nonprescribed opioids, benzodiazepines, or other drugs; and educate patients and families about overdose and harm prevention.
Opioid Selection and Dosage
Treat all opioid prescribing as a therapeutic trial. There have been no long-term(> 1 year) controlled trials of the effectiveness of opioids, and cohort studies have indicated that patients receiving long-term opioid therapy have worse pain and function outcomes than patients with similar pain conditions who are not taking opioids. Therefore, the opioid should be tapered and discontinued if it does not significantly improve pain and function at a dose of 50 mg MED 1 or if the patient experiences fatigue, sedation, or other side effects.
Start with weak opioids first. Weak opioids include codeine, tramadol products, and transdermal buprenorphine. Switch to a potent opioid only if the weak opioid is ineffective. If a potent opioid is needed, use low doses of a short-acting formulation for initial titration. Avoid fentanyl. Do not prescribe benzodiazepines concurrently with opioids.
Recommend the lowest possible dose for the shortest possible time. Low doses and slow dose titration are appropriate for all patients, but are especially important for those at risk for opioid-induced falls, sedation, and other harms. Risk factors for opioid-induced falls, sedation, and other harms include advanced age, concomitant benzodiazepine or other sedating medications, alcohol use, sleep apnea, and impairment of renal, hepatic, or respiratory function. Do not prescribe opioids for nighttime use by elderly patients who are at high risk for falls.
Advise patients about opioid-related harms and prevention of overdose. Use patient-specific handouts, such as Opioid Pain Medicines – Information for Patients and Families, to support discussion of the following issues of concern:
impairment of ability to drive or operate machinery, especially after initiation of an opioid or after an increase in dose
avoidance of the combination of opioids with alcohol, benzodiazepines, or illicit drugs
the need to alert family members and friends to the initiation of opioid treatment, as well as the symptoms and signs of opioid toxicity
the requirement for secure storage of opioids, especially if children or young adults live in the same house as the patient
the requirement to not share opioids with others or take opioids from others
MED = morphine equivalents / day, also known as morphine milligram equivalents( MME)/ day. This is the total amount of opioid consumed in a 24-hour period, converted to the morphine-equivalent daily dose in milligrams. Potency ratios: morphine = 1, oxycodone = 1.5, hydromorphone = 5( available from http:// nationalpaincentre. mcmaster. ca / opioid / cgop _ b _ app _ b08. html). 1
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Dialogue Issue 4, 2016