Pain 4 Flashcards
What are the steps in conducting an opioid trial?
- decide and document trial duration
- set and document functional goals (SMART)
- choose opioid and optimal dose
- implement with safer opioid prescribing principles, universal precautions, counselling about AEs
- reassess and measure opioid effectiveness
- monitor for adverse effects, medical complications, adherence, and risks
- end titration
- document the trial
What is considered a reasonable trial of opioids?
3-6 months
What is the lowest starting dose of an opioid for an opioid-naive patient?
5-10 MME/dose or a daily dosage of 20-30 MME/day
Which dosage form should we start with for opioids?
IR
consider transdermal buprenorphine for those who can afford it (less risk of respiratory depression, tolerance, opioid-induced hyperalgesia)
At what strength should we initiate an opioid?
start with low dose and then increase the dose in small quantities
-opioids produce a graded analgesic response
slow titration:
-avoids unnecessarily high doses
-reduces the risk of sedation and overdose as it ensures that a dose increase does not exceed the patients tolerance
What are the recommendations from Canadian Opioid Guidelines for choosing an opioid dose?
ideally restrict to < 50 MEQ/day
avoid higher than 90 MEQ/day
harms increase with doses > 50-90 MEQ
long-acting agents dosed on a scheduled basis considered more useful
What are some patient factors which further warrant starting opioids at lower doses?
increased age
decreased weight
sleep apnea
impaired renal or hepatic function
interacting drugs/concurrent CNS depressants
pulmonary disease or conditions that cause decreased pulmonary drive
seizures
risk of developing GI obstruction
What is the onset of opioids?
IV direct: 3-5 min
IV intermittent: 10-15 min
IM/SC: 10-15 min
oral: 15-30 min
How is an optimal dose reached for opioids?
with a balance of three factors:
1. effectiveness
-improved function or at least 30% decrease in pain intensity
2. plateauing
-effectiveness plateaus: increasing dose yields negligible benefit
3. adverse effects/risks
-adverse effects and risks are manageable
What is the issue with PRN opioids for breakthrough pain?
PRN opioid for breakthrough pain in CNCP can be problematic:
-patients may rely on PRN opioids
-leads to dose escalation without documented benefit on pain and function
better for patient to learn other coping strategies
PRN use may result in cycling of “pain-pain relief and subtle euphoria”
What are some important education pieces to provide with opioids?
possible functional benefits (limited in most cases)
adverse effects (common, increase over time)
drug interactions (increase of toxicity)
-may even consider deprescribing other drugs before opioid trial
importance of active, self-management strategies +/- ongoing exploration of non-opioid pharmacotherapy
How often should we follow up with a patient during an opioid trial?
q2-4 weeks
-repeat initial pain assessment questionnaires
-revisit co-created functional goals (objective improvements should be incremental, 30% subjective pain reduction=clinically significant)
-document!
What are some considerations to make before an opioid dose exceeds 90-200 MEQ/day?
has the pt shown appropriate opioid effectiveness in response to the dose increases to date?
is the diagnosis accurate?
is opioid considered effective for the patients diagnosis?
is further investigation and/or consultation required?
are non-opioid treatment options available?
is there an inadequately treated mental health disorder?
What are some medical complications of opioids?
neuroendocrine abnormalities
erectile dysfunction
sleep apnea
opioid-induced hyperalgesia
What are some extra precautions you could consider for a patient at high risk of opioid misuse?
ask the patient to bring their medication for pill counts and to explain any discrepancies
using screening tools to check for aberrant drug-related behaviours
What should be done if you suspect opioid use disorder?
assess and refer for treatment
-use precautions/tigher boundaries
treat both pain and OUD
When have we hit the “end” of an opioid trial?
- the “optimal” dose is attained
-balance of effectiveness, plateauing, adverse effects/risk - trial is considered a “failed” trial
What is a “failed” trial of opioids?
a) the patient experiences insufficient analgesia after 2-3 dose increases and/or unacceptable AEs and/or medical complications and/or risks are too high
b) there are indications of aberrant use and/or OUD
c) insufficient improvement in ability to function per SMART goals
What are some universal precautions that should be taken with opioids?
complete OUD screening with Opioid Risk Tool
one opioid prescriber, one pharmacy
urine drug screens (baseline, random q6mos)
limited quantities (total, part-fill, intervals)
lock box at home
random pill counts
treatment agreement (boundaries and rules)
What should we always have when starting an opioid?
an exit strategy
When do we consider tapering opioids?
when opioids taken > 1 week at regular intervals
What are some opioid taper precautions?
pregnancy
-severe, acute opioid withdrawal has been associated with premature labour and spontaneous abortion
unstable medical and psychiatric conditions can be worsened by anxiety associated with withdrawal
-tapering after long-term use may increase risk of overdose and mental health crises
if opioid use disorder
-may lead to accessing from unregulated sources
