Opioid Stewardship Flashcards by Jordan Cyr

Where does Canada rank among consumers of opioids?

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

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What is opioid stewardship?

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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What are the 3 pillars of opioid stewardship?

clinical work
education
quality improvement and research

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

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

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

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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What is the current model for perspective of pain?

biopsychosocial model

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Is polypharmacy rational in pain management?

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

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

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

use lower doses, slower titrations when increasing doses

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What is the goal for pain management in older adults?

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

larger push for non-pharm strategies
before starting any analgesic, review meds for polypharmacy & discontinue any unnecessary meds
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
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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What is a good assessment to do with every patient with pain?

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

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What should goals of therapy focus on with pain?

function
-dont focus on numbers or rating scales

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What is a very important aspect of pain management?

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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When can opioids be considered for pain?

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

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What is the role of opioids in chronic pain?

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

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

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

What are the 5 steps in pain management?

pain assessment (PQRSTU, goals of therapy)
optimize non-pharm options
optimize non-opioid analgesics
if pain management not sufficient, consider opioid trial
re-assessing long term use of opioids

What is the role of opioids in pain management?

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

What is the most common post-surgical complication?

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

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

source of prescription analgesics among non-medical users

How quickly can continued opioid use begin after opioid introduction?

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

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

through opioids prescribed for back pain

Differentiate overdose risk based on different MED ranges.

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

How much more potent are IV opioids compared to oral?

2x more potent

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

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

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

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

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

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

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

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*

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

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

What are the options with buprenorphine preoperatively?

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

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

hydromorphone

Which opioid is most effective intraoperatively?

sufentanil

When should we taper or rotate opioids?

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

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

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

What are the benefits of rotating to buprenorphine?

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

What are the conversion factors between opioids?

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

Differentiate between the different ways to taper an opioid.

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

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

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

What should always be provided during an opioid taper?

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

Which patients should we make naloxone available to?

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)

Provide a brief description of buprenorphines pharmacology.

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)