Chapter 13 Risk Stratification and Management of Opioids Flashcards
1. The risk-benefit profile of long-term opioids should be carefully weighed in regard to risks for misuse or addiction, endocrine deficiencies, medical comorbidities such as sleep-disordered breathing, and the development of heightened pain sensitivity. 2. Every clinician who provides opioids should be familiar with risk factors for opioid misuse or addiction, screen patients accordingly, and set a level of clinical monitoring and reassessment appropriate to the degree of risk, which may cha
ASSESSING FOR RISK OF MISUSE OR
ADDICTION
minimal prevention
measures are applied that include initial assessment,
an opioid treatment agreement, informed consent, regular urine drug tests (UDTs), regular reassessment of treatment
goals, and thorough documentation
Patients are evaluated
for the presence of
opioid-related risk factors that include personal or family history of substance misuse, young age, history of sexual abuse, mental disease, social patterns
of drug use, psychological stress, poor social support, polysubstance misuse, cigarette dependency, and repeated 2rehabilitations for substance misuse
The Screener and Opioid Assessment for Patients with Pain, Version 1 (SOAPP 1.0),
a 14-item, self administered
questionnaire that examines such predictors as history of substance misuse, sexual abuse, mood disorders, impulsivity, legal problems, and chaotic social environment
Opioid Risk Tool
is a five-item, self-report questionnaire, which provides a gender-specific
score, and can be completed in less than 5 min
The Opioid Risk Tool (ORT)
assesses for
personal and family history of substance misuse; age; history of preadolescent sexual
abuse; and the presence of certain mental disorders, and has successfully identified which patients are at lowest and highest risk
Diagnosis, Intractability,
Risk, Efficacy (DIRE)
incorporates risk factors for substance misuse in addition to characteristics regarding the patient’s pain
Rather than assigning a
patient a risk category, the DIRE purports to determine
whether the patient is a good candidate for long-term opioid therapy
Which of the three tools is sensitive for detecting high-risk patients?
SOAPP is the most sensitive of the three tools at detecting high-risk patients, followed by the ORT and then the DIRE
At each clinic visit, the patient should be reassessed for the 4As:
aberrant drug-taking behaviors
activities of daily living, adverse effects, and
analgesia,
Urine Drug Tests (UDTs
UDTs can help indicate whether illicit or unauthorized prescriptions
are present, and whether the patient is actually taking the prescribed medication.
Signs of aberrant
behavior should trigger a UDT. Two main types of UDT that are available.
Initial screening, usually a radioactive or enzyme mediated immunoassay test, can show whether substances are present but typically cannot isolate specific opioids. Confirmation testing generally requires a gas chromatography/mass spectrometry (GC/MS), which can detect actual
molecular structures of specific drugs and their metabolites. Initial testing may be done in the office, but confirmation testing is most often handled by a lab
If Urine Drug Tests (UDTs is positive, the clinician should
document and address with the patient any aberrant behaviors that arise during the course of opioid therapy and should intensify monitoring measures accordingly.
Intensified levels of monitoring may involve
limiting the amount or types of medication
prescribed, requiring frequent physician visits and UDTs, bringing in specialists to co-manage the patient, and appointing a third party to dispense medication to the patient
long-term consumption of opioids contributes to endocrine deficiencies
that long-term consumption of opioids contributes to hormone deficiencies, in particular those that produce adverse sexual side effects
adverse sexual side effects
These effects may include
decreased libido and muscle mass, erectile dysfunction fatigue, depression, hot flashes, menstrual irregularities,
weight gain, and osteoporosis
the impact of chronic opioid therapy on the endocrine system in men and women
found extensive hypogonadism in men and women primarily due to central suppression
of hypothalamic secretion of gonadotropin-releasing
hormone (GnRH)
Opioid-consuming women compared to nonopioid controls demonstrated
lower values of testosterone, estradiol, dehydroepiandrosterone
sulfate, LH, and follicle-stimulating hormone (FSH)
Men taking sustained-release opioids for pain have demonstrated significantly
lower levels of
testosterone, luteinizing hormone (LH), and other hormones than nonopioid controls
Patients taking opioids for chronic pain should be screened for
symptoms associated with abnormalities of sex hormones, and those on high-dose opioids (>100-mg morphine equivalent) should be tested for serum hormone levels.
Recommended lab tests for patients taking opioids for chronic pain include
those for total testosterone, free testosterone, estradiol, LH, and FSH. Hypogonadism is typically diagnosed at less than 300 ng/dL total (bound and free) testosterone
treatment choice in patients with abnormalities of sex hormones
recommend opioid rotation or opioid reduction accompanied by non- pharmacologic treatments for pain. If these measures are unsuccessful, hormone replacement therapy may be considered as follows:
Testosterone: gel, cream, buccal, transdermal
Estrogen
Dehydroepiandrosterone (DHEA), prasteron (INN)
(50 to 100 mg/day)
Thyroxine, Growth hormone
l Hydrocortisone
sleep-disordered breathing associated with
opioid consumption.
Complicating risk factors for apnea
benzodiazepine use, chronic pain, and high body mass index (BMI) (an apparent factor
for obstructive but not central sleep apnea)
sleep studies are advisable for patients
taking
methadone more than 40 mg per day and other
opioids at approximately 100 to 150 mg morphine equivalent per day
The conservative prescribing guidelines are
recommended for initiating or converting to methadone in patient at risk of sleep-disordered
Do not use conversion tables to determine the initial dose. Consider the patient to be opioid-naive for initiating methadone, regardless of prior opioid dose.
l Start with a ceiling dose of no more than 20 mg/day (10 mg/day for elderly or infirm patients).
l Adjust other medications down slowly while concurrently titrating methadone up slowly.
l Adjust doses no more often than weekly to allow
steady-state blood levels of methadone to develop and for the maximum respiratory-depressant effects to become clear.
l The starting dose and speed of methadone titration may need to be adjusted downward if patients are taking
concomitant benzodiazepines
Risk Stratification after Sleep Study Screening
Level 3 (highest risk)
Around-the-clock opioids with CAI. >5 events/hr
Around-the-clock opioids with AHI. >30 events/hr
Level 2 (moderate risk)
Around-the-clock opioids with AHI. >5 events/hr
Level 1 (lowest risk)
Patients with AHI , 5 events/hr
AHI apnea-hypopnea index;
CAI, central apnea index.
Opioid-induced hyperalgesia (OIH)
s a paradoxical response in which sensitivity to painful stimuli increases following opioid administration to treat pain
Opioid-induced hyperalgesia (OIH) mechanism of action
neuroplastic changes in the peripheral and central nervous systems that lead to sensitization
of pronociceptive pathways
What is the difference between OIH and tolerance?
Tolerance is a neurophysiologic adaptation of decreased analgesic effectiveness in response to desensitization of antinociceptive pathways, may be overcome by increasing doses.In contrast, OIH is characterized by lessened analgesic effectiveness coupled with an enhanced sensitivity to pain in which increasing doses may
worsen pain. OIH is also a hallmark of opioid withdrawal
To assess for the presence of OIH, other possible causes for
failure of opioid analgesia must be ruled out as follows:
Worsening pain pathology Opioid tolerance Physical withdrawal Inadequate analgesia Addiction
Means to minimize OIH or possibly to resolve it, include the following:
The lowest clinically effective opioid dose
Adjuvant medications to enhance opioid sparing
Long-acting opioids
Opioid rotation
Opioids that incorporate low-dose opioid antagonists
opioids come with
significant risks and will prove more harmful than helpful for some patients. Warning signs to look for include
no benefit from opioids despite dose adjustments, side-effect management, and/or opioid rotation; poor tolerance at
analgesic doses; persistent adherence problems despite
appropriate limits and monitoring; or the presence of a
complicating comorbid condition that renders opioid therapy
ineffective or harmful
