Opioid Stewardship

Question 1

What is opioid stewardship?

Answer 1

Coordinated interventions designed to improve, monitor, and evaluate the use of opioids in order to support and protect human health

Question 2

What treatment should be initiated for every patient with pain?

Answer 2

Initiated and maintained on appropriate scheduled non-opioid analgesic

Question 3

What is a general rule of thumb for pain management dosing?

Answer 3

Use lower doses, slower titrations when increasing doses

Question 4

What is the goal for pain management in older adults?

Answer 4

Pain management plans must consider not only pt comfort and physical function, but also strive to prevent injury, improve psychosocial function, prevent deconditioning, maintain homeostasis, and optimize QoL

Question 5

Should know the potential stepped approach of pain managment. (7 steps)

Answer 5

From the base of the pyramid first:
1. Assess pain, co-morbidities, and polypharmacy
2. Non-pharmacological strategies
3. Topical products
4. Acetaminophen
5. Co-analgesic(s) for neuropathic pain, if applicable &/or opioid, low dose, immediate release
6. Opioid, higher dose, extended release
7. NSAIDs? (with risk reduction strats)

Question 6

What is the PQRSTU mnemonic?

Answer 6

Precipitating/palliative - what makes pain better or worse?
Quality - what does the pain feel like?
Region/radiation - where do you feel the pain
Severity - pain at its worst?
Temporal - when did it start?
U (you) - how does it affect ability to complete ADLs?

Question 7

Why are non-pharm methods of pain management so important?

Answer 7

Analgesics only provide modest benefit, 30% reduction in pain at best

Question 8

Opioids for chronic pain. Yay or nay

Answer 8

Nay

Question 9

What is the opioid pendulum?

Answer 9

1. Widespread use
   - Liberal opioid prescribing
   - High incidence of opioid addiction
2. Balance
   - Rational prescribing
   - Risk stratification and principles of addiction medicine applied
   - Close monitoring
3. Opiophobia
   - Reluctance to prescribe opioids under all circumstances
   - Undertreated pain

Question 10

What is/should be the role of opioids? (2)

Answer 10

1. Severe, short-term pain
   - Often acute, painful events such as trauma, post-surgical
2. End of life or pain associated with cancer

Question 11

What is the problem with post-operative opioid prescribing?

Answer 11

Prescribing often far exceeds pain management needs; prescription size is the strongest predictor of how much opioid a person will use
- Leads to OUD

Question 12

How many days of opioid use does it take for chances of chronic use to occur?

Answer 12

3 days - increases rapidly thereafter

Question 13

The risk of chronic opioid use is?

Answer 13

Risk of OD and OUD

Question 14

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

Answer 14

Opioids prescribed for back pain

Question 15

What are the risk factors with large association with fatal and non-fatal overdoses (of opioids)? (7)

Answer 15

1. History of opioid overdose
2. 3 or more prescribers
3. 4 or more dispensing pharmacies
4. Prescription for fentanyl vs. other opioids
5. Current SUD
6. > 90 MEQ
7. Any mental health disorder

Question 16

What to discuss with patient if they have a new opioid Rx? (5)

Answer 16

1. Pain assessment (PQRSTU)
2. Non-opioid analgesics and non-pharm treatments
3. If prescription > 7 days, provide partial fill and provide rationale
4. Actual risks of short and long-term therapy
5. Dispense naloxone kit, provide education

Question 17

What to discuss/check for when a patient has an ongoing/chronic opioid Rx? (3)

Answer 17

1. Pain and FUNCTION
2. Up to date naloxone kit at home
3. Worrisome patterns
   - Multiple pharmacies?
   - Multiple providers?

Question 18

What if your patient has an opioid prescription and they have known opioid use disorder? (2 things to check)

Answer 18

1. If active OUD, do they need further support?
   - Initiate OAT?
   - Withdrawal support?
   - Naloxone kit
2. Are they on OAT + experiencing acute pain?

Question 19

Why should we not discontinue or reduce buprenorphine perioperatively or in the context of acute pain requiring additional opioid analgesia? (4)

Answer 19

1. Risk of opioid withdrawal and poor pain management
2. Challenge to restabilize OUD or chronic pain treatment, and risk of precipitated opioid withdrawal with buprenorphine re-initiation
3. Risk of return to use (OUD) and unintentional overdose
4. Patient-centred approach

Question 20

What are the top 3 opioids with the highest affinity for the mu opioid receptor?

Answer 20

1. Sufentanil
2. Buprenorphine
3. Hydromorphone

Question 21

When should we taper/rotate opioid? (7)

Answer 21

1. No meaningful improvement in FUNCTION and pain
2. Chronic high use of opioids (>50-90 MEQ)
3. Pt experiencing side-effects or overdose
4. Opioid-induced hyperalgesia
5. Intolerable side effects
6. Signs of SUD
7. Requesting dose reduction

Question 22

What is the clinical presentation of opioid-induced hyperalgesia? (4)

Answer 22

1. Generalized, diffuse pain, may not be associated with original pain
2. Exaggerated sensitivity/response to painful stimuli OR non-painful stimuli (allodynia)
3. Increasing opioid dose may provide temporary analgesia, but will worsen over time
4. Pain will improve with decreasing opioid dose, return to baseline with opioid cessation

Question 23

What are 3 management strategies for opioid-induced hyperalgesia?

Answer 23

1. Opioid rotation
2. Opioid taper
3. Adjunctive agents such as ketamine or lidocaine

Question 24

Why is opioid-induced hyperalgesia underdiagnosed?

Answer 24

Frequently misinterpreted as increasing pain cycle and normal tolerance

Question 25

Parenteral opioid is _x more potent than oral

Answer 25

2

Question 26

When doing an opioid rotation, what is the main one we should consider rotating to?

Answer 26

Buprenorphine