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Substance Use Disorders > Opioid Stewardship > Flashcards

Opioid Stewardship Flashcards

1
Q

Opioid stewardship may be described as…

A

Coordinated interventions designed to improve, monitor, and evaluate usage of opioids to support + protect human health

Right pt, right medication, right dose, right indication, right length of time

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2
Q

Opioid stewardship encompasses usage for indication including…

A

Pain
Mental health (MDD and PTSD correlated with chronic pain)
SUD - OUD, trauma, chronic pain

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3
Q

Perception of pain involves ____, but is heavily influenced by…

A

Several inputs + outputs to pain processing neuromatrix in the brain, and is heavily influenced by biological, motivational/emotional, and cognitive factors

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4
Q

Every patient with pain should be…

A

Initiated and maintained on appropriate scheduled non-opioid analgesics

Appropriate dose for appropriate trial

Topical agents,
Acet, NSAID’s if safe
Duloxetine, pregabalin, gabapentin

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5
Q

If opioids are required, they should be used…

A

For the lowest effective dose for the shortest period of time

While maintaining non-opioid analgesics

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6
Q

Polypharmacy may be necessary due to…

A

The presence of multiple factors impacting pain and the different MOA’s from medication required

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7
Q

Chronic pain is common in older adults, and most commonly presents as…

A

Osteoarthritis
Myofascial pain
Lower back pain

Older adults tend to be on more medications for chronic conditions

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8
Q

Older adults are at increased risk of AE’s from opioids such as…

A

Cognitive changes, dizziness, potential falls

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9
Q

A good rule for dosing opioids (and most medications) for older adults is…

A

Use lower doses, and slower titrations when increasing doses

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10
Q

Goal for pain management in older adults should consider…

A

Not only patient comfort and physical function, but also to prevent injury, improve psychosocial function, prevent deconditioning, maintain homeostasis, optimize quality of life

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11
Q

Pain management with older adults vs. the general population involves…

A
  1. Pushing for non-pharmacologic strategies
  2. Review meds for polypharmacy + discontinue unnecessary meds
  3. Topical agents > Acet > NSAID’s (duloxetine 1st line for specific pain
  4. If opioids used, start at 1/2 dose and be careful with SR formulations
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12
Q

If a patient is on long-term opioids, a good course of action is to…

A

Assess function + goals of therapy
Ensure non-pharmacological + non-opioid analgesics
Still effective? If stable 6-12 months consider tapering
Assessment for hyperalgesia

Naloxone kit??

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13
Q

Opioids are not effective for…

A

Chronic pain; nociplastic, neuropathic

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14
Q

Long-term risks of opioids may involve…

A

Immunosuppression
Suppression of HPA-axis
>50 MED associated with 2x risk of fractures, hyperalgesia, OUD, overdoses

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15
Q

The opioid pendulum describes a swing between…

3 stages; describe

A

Widespread use (liberal opioid prescribing, high incidence of addiction)

Opiophobia (reluctance to prescribe, undertreated pain)

Balance (rational prescrbining, risk stratification, close monitoring)

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16
Q

The role of opioids involves…

A

Treating severe, short-term pain
End of life or pain associated with cancer

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17
Q

The most common post-surgical complication is…

A

Becoming a new chronic opioid user

Beyond 3 month usage

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18
Q

The strongest predictor of how much opioid a person will use is…

A

Prescription size

Prescribing often far exceeds pain management needs, 92% patients have leftover opioids after surgery

19
Q

Chances of continued opioid use begins to increase after…

A

The third day of opioid introduction, and rise rapidly thereafter

Likelihood of chronic use increases with each additional day

20
Q

The most comon entry point to prescription opioid addiction is through…

A

Opioids prescribed for back pain

20
Q

Chronic opioid use increases risk of…

A

Overdose and opioid use disorder

21
Q

Risk factors that have a large association with overdose include…

A

Hx of opioid overdose, 3+ prescribers, 4+ dispensing pharmacies, fentanyl, current SUD

Any mental health disorder
>90mg MED

Also includes opioid + CNS depressant, long-acting formulations, chronic opioid rx, schedule + PRN, chronic condition

22
Q

Forced or aggressive tapering/discontinuation of opioids is associated with…

A

An INCREASE risk of overdose and death

23
Q

Factors in acute care that drive risk of dependence and overdose include…

Can be incorporated into opioid stewardship practices

A

High daily MED
Multiple opioids ordered, IV formulation
No naloxone ordered
Long-acting opioids for acute pain in opioid naive patients
Combining benzos + opioids

24
Q

IV opioid use beyond 7 days…

A

Drives tolerance, and increases frequency of use

80% of parenteral opioid usage could have been given PO

25
Q

Opioid stewardship practices that can be implemented into community when dispensing a new opioid Rx includes…

A

Conducting pain assessment
Non-opioid analgesics + non-pharmacological tx
If Rx > 7 days, provide partial fill and provide rationale
Actual risks of short + long term therapy

Give naloxone

26
Q

Opioid stewardship practices that can be implemented into community when dispensing an ongoing/chronic opioid Rx includes…

A

Monitoring pain + function (optimizing non-opioid, non-pharm, assessing effectiveness and tolerance developing?)
Up to date naloxone
Check for worrisome patterns (multiple pharmacies, providers?)

27
Q

If someone with active OUD gets an opioid prescription, what should we do?

A

Initiate OAT if hasn’t been done, discuss withdrawal support
Ensure patient has naloxone kit + other harm reduction measures

28
Q

If someone on OAT is experiencing acute pain, what should we do?

A

Treat like any other patient; non-drug, non-opioid first
If receiving methadone/suboxone, splitting dose TID-QID can aid in pain management
If receiving suboxone/sublocade - smal dose suboxone SL q4h PRN

If non-opioid analgesic optimized, discuss risk vs. harms of short-term opioid with patient and/or physician

Sometimes it IS appropriate and in patient’s best interest to give opioids to someone with OUD

29
Q

Buprenorphine should NOT be discontinued or dose reduced perioperatively, or in context of acute pain requiring additional opioid. This is because…

A
  1. Risk of opioid withdrawal + poor pain management
  2. Challenge to restabilize OUD/chronic pain tx. Risk of precipitated opioid withdrawal with buprenorphine re-initiation
  3. Risk of return to use, and unintentional overdose

Take a patient-centered approach

30
Q

Treatments for post-op pain while on suboxone may include…

Similar to pain for someone on OAT

A
  1. Divide current/increased buprenorphine dose into TID/QID dosing
  2. Continue same dose of buprenorphine and add analgesics + non-pharm strategies
  3. Reduce buprenorphone dose 2-3 days before surgery to free up Mu opioid receptors and add IR opioids

Option 3 is not the best

31
Q

If additional opioid is required while a patient is receiving buprenorphine, these are the only ones that can be used…

A

Hydromorphone
Sufentanil (intraoperatively)

Affinities for Mu opioid receptor

32
Q

An opioid taper/rotation has no meaningful improvement in function/pain, but is mostly used for…

A

Patient experiencing AE’s or OD
Opioid-induced hyperalgesia
Signs of SUD
Patient requesting dose reduction

33
Q

Opioid-induced hyperalgesia presents as…

A

Generalized, diffuse pain; exaggerated sensitivity/response to painful or non-painful stimuli

34
Q

Increasing opioid dose in hyperalgesia…

A

May provide temporary analgesia, but will worsen over time

Pain will improve with decreasing opioid dose, return to baseline with opioid cessation

35
Q

Risk of opioid-induced hyperalgesia increases with…

A

Prolonged opioid use - higher dose and longer durations

36
Q

Management strategies for opioid-induced hyperalgesia includes…

A

Opioid rotation or taper
Adjunctive agents such as ketamine or lidocaine

37
Q

When considering opioid rotation, an opioid we should think about is…

A

Buprenorphine - microdose initiation

Comes with benefits - reduced hyperalgesia, tolerance, immunosuppression, sexual, overdose risk
Can be used PRN in acute pain

38
Q

A rapid taper should be done if a patient is experiencing…

A

Major side effects
Hyperalgesia
Overdose

25% reduction q3-5 days, over 1-2 weeks

39
Q

A gradual taper should be done if…

A

Patient is stable and willing to attempt taper
Patient has been receiving a high dose for a long period of time (1+ year)

5-10% reduction q2-4 weeks over several weeks
Once 1/3 of original dose, may need to slow rate to q4-8 weeks

40
Q

Tapering may be easier if opioids are rotated first, because…

A

Reduces MED by 50%
Receptors are more sensitive

41
Q

When tapering, always provide…

A

PRN opioids
Withdrawal support medications
Optimized non-opioid analgesics

42
Q

Naloxone should be available for…

A

All individuals using opioids (Rx or other), especially those at increased risk of overdose

Substance Use Disorders (6 decks)

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