Opioid Stewardship Flashcards
Opioid stewardship may be described as…
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
Opioid stewardship encompasses usage for indication including…
Pain
Mental health (MDD and PTSD correlated with chronic pain)
SUD - OUD, trauma, chronic pain
Perception of pain involves ____, but is heavily influenced by…
Several inputs + outputs to pain processing neuromatrix in the brain, and is heavily influenced by biological, motivational/emotional, and cognitive factors
Every patient with pain should be…
Initiated and maintained on appropriate scheduled non-opioid analgesics
Appropriate dose for appropriate trial
Topical agents,
Acet, NSAID’s if safe
Duloxetine, pregabalin, gabapentin
If opioids are required, they should be used…
For the lowest effective dose for the shortest period of time
While maintaining non-opioid analgesics
Polypharmacy may be necessary due to…
The presence of multiple factors impacting pain and the different MOA’s from medication required
Chronic pain is common in older adults, and most commonly presents as…
Osteoarthritis
Myofascial pain
Lower back pain
Older adults tend to be on more medications for chronic conditions
Older adults are at increased risk of AE’s from opioids such as…
Cognitive changes, dizziness, potential falls
A good rule for dosing opioids (and most medications) for older adults is…
Use lower doses, and slower titrations when increasing doses
Goal for pain management in older adults should consider…
Not only patient comfort and physical function, but also to prevent injury, improve psychosocial function, prevent deconditioning, maintain homeostasis, optimize quality of life
Pain management with older adults vs. the general population involves…
- Pushing for non-pharmacologic strategies
- Review meds for polypharmacy + discontinue unnecessary meds
- Topical agents > Acet > NSAID’s (duloxetine 1st line for specific pain
- If opioids used, start at 1/2 dose and be careful with SR formulations
If a patient is on long-term opioids, a good course of action is to…
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??
Opioids are not effective for…
Chronic pain; nociplastic, neuropathic
Long-term risks of opioids may involve…
Immunosuppression
Suppression of HPA-axis
>50 MED associated with 2x risk of fractures, hyperalgesia, OUD, overdoses
The opioid pendulum describes a swing between…
3 stages; describe
Widespread use (liberal opioid prescribing, high incidence of addiction)
Opiophobia (reluctance to prescribe, undertreated pain)
Balance (rational prescrbining, risk stratification, close monitoring)
The role of opioids involves…
Treating severe, short-term pain
End of life or pain associated with cancer
The most common post-surgical complication is…
Becoming a new chronic opioid user
Beyond 3 month usage
The strongest predictor of how much opioid a person will use is…
Prescription size
Prescribing often far exceeds pain management needs, 92% patients have leftover opioids after surgery
Chances of continued opioid use begins to increase after…
The third day of opioid introduction, and rise rapidly thereafter
Likelihood of chronic use increases with each additional day
The most comon entry point to prescription opioid addiction is through…
Opioids prescribed for back pain
Chronic opioid use increases risk of…
Overdose and opioid use disorder
Risk factors that have a large association with overdose include…
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
Forced or aggressive tapering/discontinuation of opioids is associated with…
An INCREASE risk of overdose and death
Factors in acute care that drive risk of dependence and overdose include…
Can be incorporated into opioid stewardship practices
High daily MED
Multiple opioids ordered, IV formulation
No naloxone ordered
Long-acting opioids for acute pain in opioid naive patients
Combining benzos + opioids
IV opioid use beyond 7 days…
Drives tolerance, and increases frequency of use
80% of parenteral opioid usage could have been given PO
Opioid stewardship practices that can be implemented into community when dispensing a new opioid Rx includes…
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
Opioid stewardship practices that can be implemented into community when dispensing an ongoing/chronic opioid Rx includes…
Monitoring pain + function (optimizing non-opioid, non-pharm, assessing effectiveness and tolerance developing?)
Up to date naloxone
Check for worrisome patterns (multiple pharmacies, providers?)
If someone with active OUD gets an opioid prescription, what should we do?
Initiate OAT if hasn’t been done, discuss withdrawal support
Ensure patient has naloxone kit + other harm reduction measures
If someone on OAT is experiencing acute pain, what should we do?
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
Buprenorphine should NOT be discontinued or dose reduced perioperatively, or in context of acute pain requiring additional opioid. This is because…
- Risk of opioid withdrawal + poor pain management
- Challenge to restabilize OUD/chronic pain tx. Risk of precipitated opioid withdrawal with buprenorphine re-initiation
- Risk of return to use, and unintentional overdose
Take a patient-centered approach
Treatments for post-op pain while on suboxone may include…
Similar to pain for someone on OAT
- Divide current/increased buprenorphine dose into TID/QID dosing
- Continue same dose of buprenorphine and add analgesics + non-pharm strategies
- Reduce buprenorphone dose 2-3 days before surgery to free up Mu opioid receptors and add IR opioids
Option 3 is not the best
If additional opioid is required while a patient is receiving buprenorphine, these are the only ones that can be used…
Hydromorphone
Sufentanil (intraoperatively)
Affinities for Mu opioid receptor
An opioid taper/rotation has no meaningful improvement in function/pain, but is mostly used for…
Patient experiencing AE’s or OD
Opioid-induced hyperalgesia
Signs of SUD
Patient requesting dose reduction
Opioid-induced hyperalgesia presents as…
Generalized, diffuse pain; exaggerated sensitivity/response to painful or non-painful stimuli
Increasing opioid dose in hyperalgesia…
May provide temporary analgesia, but will worsen over time
Pain will improve with decreasing opioid dose, return to baseline with opioid cessation
Risk of opioid-induced hyperalgesia increases with…
Prolonged opioid use - higher dose and longer durations
Management strategies for opioid-induced hyperalgesia includes…
Opioid rotation or taper
Adjunctive agents such as ketamine or lidocaine
When considering opioid rotation, an opioid we should think about is…
Buprenorphine - microdose initiation
Comes with benefits - reduced hyperalgesia, tolerance, immunosuppression, sexual, overdose risk
Can be used PRN in acute pain
A rapid taper should be done if a patient is experiencing…
Major side effects
Hyperalgesia
Overdose
25% reduction q3-5 days, over 1-2 weeks
A gradual taper should be done if…
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
Tapering may be easier if opioids are rotated first, because…
Reduces MED by 50%
Receptors are more sensitive
When tapering, always provide…
PRN opioids
Withdrawal support medications
Optimized non-opioid analgesics
Naloxone should be available for…
All individuals using opioids (Rx or other), especially those at increased risk of overdose
