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PHAR358 > Opioid Stewardship > Flashcards

Opioid Stewardship Flashcards

1
Q

Where does Canada rank among consumers of opioids?

A

2nd
-4.8 million Canadians take prescription opioids
-5% of those go on to injection use

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2
Q

What is opioid stewardship?

A

opioid stewardship may be described as coordinated interventions designed to improve, monitor, and evaluate the use of opioids in order to support and protect human health

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3
Q

What are the 3 pillars of opioid stewardship?

A

clinical work
education
quality improvement and research

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4
Q

What are the three topics that are covered under the umbrella of opioid stewardship?

A

mental health
opioid-use disorder
chronic pain
patients rarely fit into one category

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5
Q

What are the different inputs to the pain processing neuromatrix in the brain?

A

sensory - discriminative
motivational - affective
cognitive - evaluative
motivational and cognitive may have the largest input on how the brain perceives pain and sends that message back down

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6
Q

What is the current model for perspective of pain?

A

biopsychosocial model

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7
Q

Is polypharmacy rational in pain management?

A

yes
drugs have different MOAs and work on different parts of the ascending and descending pathways

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8
Q

How should pharmacotherapy be initiated for every patient requiring pain management?

A

every patient with pain should be initiated and maintained on appropriate scheduled non-opioid analgesics
-topicals, acet, NSAIDs, duloxetine, gabapentin, pregabalin
if opioids are required, lowest effective dose for shortest period of time and ALWAYS maintain non-opioid analgesics

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9
Q

What is the general rule of thumb with opioids in older adults?

A

use lower doses, slower titrations when increasing doses

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10
Q

What is the goal for pain management in older adults?

A

consider not only patient comfort and physical function but also strive to prevent injury, improve psychosocial function, prevent deconditioning, maintain homeostasis, and optimize QoL

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11
Q

Differentiate pain management in older adults compared to the general population.

A
  1. larger push for non-pharm strategies
  2. before starting any analgesic, review meds for polypharmacy & discontinue any unnecessary meds
  3. clearly defined steps for non-opioids
    -topical agents first
    -acetaminophen 2nd line
    -NSAIDs are often last line due to risks
    -consider duloxetine first for neuropathic pain, lower back and OA pain
  4. if opioids need to be used, start at half the dose vs general population AND be cautious if/when starting SR formulations
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12
Q

What is a good assessment to do with every patient with pain?

A

PQRSTU
precipitating/palliative
quality
region/radiation
severity
temporal
U (you = how does it impact daily life?)

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13
Q

What should goals of therapy focus on with pain?

A

function
-dont focus on numbers or rating scales

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14
Q

What is a very important aspect of pain management?

A

non-pharm
-CBT, psychotherapy
-exercise, physiotherapy, TENS
-yoga, mindfulness
analgesics only provide modest benefit, 30% reduction in pain at best = non-pharm is so important

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15
Q

When can opioids be considered for pain?

A

if pain management is not sufficient
-continue non-pharm and non-opioid analgesics
-assess goals of therapy & expectations

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16
Q

What is the role of opioids in chronic pain?

A

not effective for chronic pain
minimal/weak evidence in nociplastic or neuropathic pain (with some evidence for methadone and buprenorphine)

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17
Q

What are some things we should be considering if a patient has been on long-term opioids?

A

assessing function and goals of therapy
continuing non-pharm + non-opioid analgesics
still effective?
-if stable 6-12 months, consider taper trial
-if not effective, rotation of opioid or taper off
assessing for hyperalgesia esp if patient is increasing dose often

18
Q

What are the 5 steps in pain management?

A
  1. pain assessment (PQRSTU, goals of therapy)
  2. optimize non-pharm options
  3. optimize non-opioid analgesics
  4. if pain management not sufficient, consider opioid trial
  5. re-assessing long term use of opioids
19
Q

What is the role of opioids in pain management?

A

severe, short-term pain
-i.e. acute events
end of life or pain associated with cancer
when used short-term, rarely progress to OUD

20
Q

What is the most common post-surgical complication?

A

becoming a chronic opioid user
-prescribing often far exceeds pain management needs
-50% of patients initiated on opioids post-op are discharged with a prescription

21
Q

92% of patients post-op have leftover opioids after surgery, what is the risk?

A

source of prescription analgesics among non-medical users

22
Q

How quickly can continued opioid use begin after opioid introduction?

A

chances increase after just the 3rd day of opioid introduction and rise rapidly thereafter
-likelihood of chronic use increases with each additional day
-chronic opioid use = risk of overdose and OUD

23
Q

What is the most common entry point to prescription opioid addiction?

A

through opioids prescribed for back pain

24
Q

Differentiate overdose risk based on different MED ranges.

A

MED 0-50
-lowest risk of harms
-safest dosing range
MED 50-100
-5x increase in overdose
-avoid doses > 90 MED
MED 100-200
-9x increase in overdose
->100 more likely to be fatal
MED > 200
-9x increase in overdose
-increased rates of complications

25
Q

How much more potent are IV opioids compared to oral?

A

2x more potent

26
Q

What are many of the things being done wrong with opioid prescribing?

A

high daily MED
multiple opioids ordered
IV opioids
no naloxone ordered
avoid long-acting opioids for acute pain in opioid-naive patients
combination opioids + benzos
substance use management

27
Q

Why should long-acting opioids be avoided for acute pain in opioid-naive patients?

A

acute pain lasts 3-7 days, no reason for long acting

28
Q

What are some important things to discuss with a new opioid prescription?

A

go back to the PQRSTU
-short term? type of pain?
-expectations of pain, opioid expectations
non-opioid analgesics and non-pharm treatments
-role in therapy, importance of scheduled
if prescription > 7 days, provide partial fill and provide rationale
actual risks of short & long term therapy
dispense naloxone kit, provide education

29
Q

What are some key points to assess if receiving a prescription for an opioid for someone with OUD?

A
  1. if active OUD, do they need further support?
    -initiate OAT?
    -withdrawal support?
    -naloxone kit
  2. are they on OAT + experiencing acute pain?
    -walk through assessment list as any other patient
    -if receiving methadone or Suboxone, splitting doses to TID-QID can aid in pain management
    -small dose Suboxone 2/0.5 mg SL q4h PRN instead of other PRN opioid
    remember opioid pendulum, sometimes it is appropriate and in patients best interest to give opioids to someone with OUD
30
Q

What is the risk of discontinuing or reducing buprenorphine perioperatively or in the context of acute pain requiring additional opioid analgesia?

A

risk of opioid withdrawal and poor pain management
challenge to restabilize OUD or chronic pain treatment and risk of precipitated opioid withdrawal with buprenorphine re-initiation
risk to return to OUD and unintentional overdose

31
Q

What are the options with buprenorphine preoperatively?

A

divide current or increased buprenorphine dose into TID-QID
continue same dose but add analgesics and non-pharm
reduce buprenorphine dose to 8-12 mg/day 2-3 days before surgery to free up mu receptors and add IR opioids

32
Q

Which opioid will bind to opioid receptor the best if additional opioid is needed while receiving buprenorphine?

A

hydromorphone

33
Q

Which opioid is most effective intraoperatively?

A

sufentanil

34
Q

When should we taper or rotate opioids?

A

no meaningful improvement in function and pain
chronic high use of opioids ( > 50-90 MED)
patient experiencing AE or overdose
opioid-induced hyperalgesia
signs of SUD
requesting dose reduction

35
Q

When are some considerations to keep in mind when rotating to another opioid?

A

convert to daily MED
incomplete cross-tolerance –> decrease by 25-50%
if PRN, should be 10% of total daily dose

36
Q

What are the benefits of rotating to buprenorphine?

A

reduced hyperalgesia, immunosuppression, sexual/fertility AE, and overdose risk
can use as PRN in acute pain

37
Q

What are the conversion factors between opioids?

A

morphine: 1
codeine: 0.15
hydromorphone: 5
oxycodone: 1.5
buprenorphine: 3
multiply MED by the above

38
Q

Differentiate between the different ways to taper an opioid.

A

gradual taper:
-5-10% reduction q2-4wks over several weeks, once 1/3 of original dose may need to slow rate of taper to q4-8wks
-decreases risk of pain recurrence, withdrawal symptoms
rapid taper:
-25% reduction q3-5d, occurs over 1-2 wks

39
Q

How do we choose between the different ways to taper an opioid?

A

rapid: major AE’s, overdose, hyperalgesia
gradual: patient stable, willing to attempt taper, high dose for long period of time

40
Q

What should always be provided during an opioid taper?

A

prn opioids + withdrawal support medications + optimized non-opioid analgesics

41
Q

Which patients should we make naloxone available to?

A

all individuals using opioids
-especially those at increased overdose risk (history of SUD with reduced tolerance, previous overdose, mental health disorders, combo BZD + opioids, > 50 MED/day)

42
Q

Provide a brief description of buprenorphines pharmacology.

A

partial mu opioid receptor agonist
-dose related ceiling effect on resp dep and euphoria
-decreased overdose risk
-decreased addiction, tolerance, withdrawal
-decreased constipation, hypogonadism, immunosup
kappa opioid receptor antagonist
delta opioid receptor antagonist
reduced ORL-1 affinity
blocks monoamine uptake (less serotonin syndrome risk)

PHAR358 (14 decks)

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