7.7 (9.5) Opioid therapy: Managing risks of abuse, addiction, and diversion Flashcards
Name 2 of each of the following categories as risk factors for OUD:
- Pain related
- Mental health related
- Social
- Substance related
- Genetics (only 1 for this category)
- Demographics
What is the most strongly predictive risk factor for OUD?
Pain related
1. Back pain
2. Pain at multiple sites
3. More intense pain
Mental health
1. Mental health disorder
2. Childhood abuse or trauma
3. History or current substance use disorder (strongest predictive risk factor)
Social
1. Lack of strong support system
2. Homeless
3. Poverty
4. legal problems
Substance related
1. Current smoker
2. Current use of ETOH
3. Current use of high doses of opioids (MEDD >120mg)
Genetics
1. Family history of substance use disorder
Demographics
1. Younger age
2. Male
3. Caucasian
What is opioid diversion?
Taking a prescription medication out of its legal and appropriate distribution channels
A patient with cancer pain is on morphine 15mg PO q4h. After one month the patient requires 20mg PO q4h to maintain the same analgesia. What is this phenomenon called? What else could this indicate?
Tolerance - need for increasing doses of a medication to facilitate an effect
but also could be related to disease progression
no clinical evidence to suggest harbinger of substance dependence
A patient with cancer pain is on morphine 60mg PO q12h. The patient refills their prescription late because of a family emergency and misses three doses of medication. The patient develops anxiety, irritability, sweating and piloerection. These symptoms abate when the patient resumes morphine. What is this phenomenon? What does it indicate? Is the patient at risk of opioid addiction?
Withdrawal
Physical dependence on opioid - presence of withdrawal alone with cessation of use or administration of an antagonist
patients with physical dependence are able to stop opioid use without problematic substance use behaviours
What are the elements of substance dependence according to the DSM? What are two examples of behaviours that suggest physical dependence?
Substance dependence is a syndrome that requires maladaptive substance use with drug seeking behaviour and physical indicators of use including tolerance and withdrawal
FS
- Continued use despite negative impact on physical, psychological or social dimensions (eg missing work/school, disrupting relationships)
- Loss of control (unable to cut down)
- Compulsive (using in larger quantities or longer time)
- Craving (can also have tolerance and withdrawal)
Cont cont comp crave
What are three examples of mildly aberrant drug related behaviours?
(6th edition does not differentiate mild versus high aberrant behav.)
requests for specific pain medication
frequent prescription losses
hoarding drugs
What are three examples of high aberrant drug related behaviours
(6th edition does not differentiate mild versus high aberrant behav.)
forging prescriptions
use of illicit drugs or controlled substances that are not prescribed
altering route: crushing sustained release tablets for snorting or injecting
demanding behaviours
A patient admitted to the PCU requests a PRN dose of pain med q1h and is felt to be watching the clock. They ask for the dose to be increased every 4-8h when their next scheduled dose is due. The patient often asks the nurse when their next dose is due despite being drowsy. The report horrible pain despite no objective signs of pain on assessment. 48 hours later the patient’s opioid dose has doubled and they report a drop in pain. PRN use drops to 1-2 per day. What is this phenomenon called?
Pseudoaddiction - pts with unrelieved pain may manifest intense concern about opioid availability abd drug seeking behaviour that is reminiscent of addiction but disappears when pain relieved often through opioid dose escalation
Aberrant drug taking behaviour should trigger what? What are three examples of what it may represent beside OUD?
A fullsome assessment and screen for substance dependence
3 alternatives:
- pseudoaddiction
- underlying psychiatric illness (anxiety/PD)
- chemical coping - poor adaptive coping with stressors associated with chronic medical illness, cognitive deficits
List four professionals essential on a multidisciplinary team for the care of a patient with a history of substance misuse and also has cancer pain requiring opioids
psychologist trained in addiction
nursing
social worker
prescriber/MD
List two tools that can be used to screen for OUD in patients with chronic cancer pain. What does the COMM help with?
SOAPP - Screener and opioid assessment for patients with pain
Opioid risk tool (ORT)
COMM - current opioid misuse measure - 17 item self reported questionaire that can identify whether a patient on long term opioids is exhibiting aberrant behaviours associated with misuse
What are universal precautions for opioid therapy? (8)
- Pain assessment
- OUD risk assessment
- Diagnosis
- Informed consent
- Patient-provider agreements
- Documentation
- Clinical supervision (including compliance)
- Periodic review of therapeutic goals and comorbidities
How to check for compliance? Name 4 ways
Urine drug assays
Pill count
Review prescription monitoring programs (eg pharmanet)
Review medical records (e.g. number of ER visits)
How often to follow up a low risk vs high risk patient with opioid prescription?
Low risk - 3 months (or when there is a change in pain, mood, mental health, etc.)
High risk - monthly
You are managing an outpatient who is at risk of substance misuse. What are 3 interventions you can take as part of your treatment plan to ensure patient safety
written treatment contract that is mutually agreed upon and establishes boundaries of tx*
Prescribe: limited amount of drug dispensed per prescription, refills contingent on clinic attendance*
Compliance: urine toxicology*
involve family members and friends in the treatment plan
