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Opioid Risk Management
Besides the potential for opioid analgesia adverse effects, which often can be controlled by safe prescribing practices, the risks of greatest concern have been opioid diversion, misuse, abuse, and addiction. Documents in this section offer guidance for better opioid risk management, including: patient risk assessment, risk minimization, and compliance monitoring.
NOTE: All URL links listed below were valid at the time of posting; however, the Internet is constantly changing and some linked sites may move or become inactive with time. Please notify us of any broken links at: Info2@Pain-Topics.org
Managing Opioid Emergencies
Opioid Rescue & Disaster Preparedness
Patients and their caregivers need to know how to distinguish opioid overmedication from overdose, and how to take appropriate emergency actions for each. Many tragic opioid overdose fatalities might be avoided by such education. In other cases, disruption of access to pain-relieving medications during disasters can cause distress and discomfort for patients maintained on opioids and other pain-relieving medications. This came to light during the U.S. Gulf Coast hurricanes in 2005, which caused many hardships for patients and healthcare providers alike. Knowing how to prepare in advance for such disasters and/or how to taper the medications in an emergency to curtail withdrawal can be extremely important. Documents in this section provide vital guidance for healthcare providers, which then can be passed along to patients and their caregivers.
Opioid Overdose Prevention Toolkit
From: U.S. Substance Abuse and Mental Health Services Administration (SAMHSA); August 2013.
Access here: http://store.samhsa.gov/product/SMA13-4742
This special program was designed to help reduce the number of fatal opioid overdoses by providing education for clinicians, patients, communities, first responders, overdose survivors and family members. Of some importance, the free series of 5 documents highlights the importance of access to naloxone, an effective and safe drug for reversing the effects of overdose from opioids (whether heroin or prescription analgesics). The Toolkit stresses that, with proper education, patients on opioid therapy and others at risk for overdose may benefit from having naloxone on hand for use in the event of overdose. Access checked 8/29/2013.
What to Know About Opioid Analgesic Overdose
From: Pain-Topics News/Research UPDATES, 2012.
Accesss here: http://updates.pain-topics.org/2012/07/what-to-know-about-opioid-analgesic.html
A new review article discussing the management of life-threatening opioid analgesic overdose describes essential principles and practices that every healthcare provider, as well as educated patients, absolutely must know about. There are some surprising revelations, since prior guidance on this subject cannot be applied to opioids used for pain treatment. Access checked 7/20/2012.
Managing An Opioid Crisis [for Patients/Caregivers]
What to know. What to do.
From: Opioids911-Safety; Stewart B. Leavitt, MA, PhD; 2010.
These documents are from Opioids911-Safety, an independent, noncommercial, Internet-based educational activity from Pain Treatment Topics for patients and their caregivers focusing on the proper and safe use of opioid pain relievers. Besides providing necessary education on understanding opioid analgesics and safety precautions, instruction is provided on recognizing opioid problems — eg, overmedication or overdose — if they occur and on being prepared for what to do during an emergency. Access checked 5/27/11.
Signs to Watch For - Overmedication or Overdose?
Overdose Emergencies - What to Do Until Help Comes
Emergency Opioid Tapering
Emergency Opioid Tapering
Opioid Tapering: Safely Discontinuing Opioid Analgesics
From: Pain Treatment Topics - Lee A. Kral, PharmD, BCPS, March 2006.
PDF available here for download: Safely_Tapering_Opioids.pdf (140 KB; 7 pp)
This paper discusses the many factors to consider when discontinuing opioid analgesics, and it presents specific and practical clinical guidance for establishing protocols that maximize patient safety and comfort during the process. Important advice for patients regarding emergency tapering – such as following natural disasters or other crises when medication is inaccessible – also is provided. Access verified 6/15/09.
Naloxone for Reversing Opioid Overdose or Overmedication
There have been serious concerns about increases of overdose deaths associated with prescribed and illicit opioid agents. Naloxone is an effective and relatively safe antidote for the complete or partial reversal of opioid overmedication or overdose, including fatal respiratory depression, induced by natural and synthetic opioids. Because of the very short duration of action of naloxone (approx. 20-60 minutes) its reversal of opioid-induced respiratory depression may cease while the opioid action persists. Therefore, respiratory depression may recur and patients should continue to be very closely observed. Also note that, since naloxone reverses the effects of opioids, it may precipitate symptoms of withdrawal (eg, pain, hypertension, irritability) in patients maintained on or addicted to opioids. Naloxone (once sold as Narcan® and other brands) is available as a generic, and prefilled-syringe products are also available for home use.
NOTE: Product information indicates that naloxone may be administered via intravenous (IV, which is preferred), intramuscular (IM), or subcutaneous (SC) routes. Dosing is typically specified for IV administration; however, dosing is the same for IM, or SC administration, although onset of action may be slightly slower and duration of effect may be longer with these other routes. Intranasal administration – via use of an atomizer device – also has been used successfully (“off-label”).
Overdose Prevention & Naloxone: Manual and Resources
From: Harm Reduction Coalition, 2012.
This manual and its associated resources provide detailed guidance for developing and managing an Overdose Prevention and Education Program, with or without the use of a take-home naloxone component. Overdose prevention efforts can be easily integrated into existing programs or settings that encounter people who might misuse drugs. These include healthcare services or community programs, pain treatment practitioners/clinics, parent and student groups, substance abuse treatment programs, and others.
Providing overdose prevention, recognition, and response education to pain patients or drug users — and their neighbors, friends, families, and the service providers who work with them — is a harm reduction intervention that saves lives. Opioid overdoses are particularly amenable to intervention because risk factors are well understood and there is a safe antidote — naloxone. Access checked 11/16/2012.
Go to resources here: http://harmreduction.org/issues/overdose-prevention/.../od-manual/
Prescribe to Prevent
(Prescribe Naloxone… Save a Life)
This website features helpful information and resources to start prescribing naloxone for at-home overdose rescue in patients who are prescribed opioid analgesics. Sections include where to get naloxone and how to bill for it, how to train patients/caregivers, medicolegal considerations, research and informational resources, FAQs, and more. Access checked 3/16/2012.
Visit the website here: http://prescribetoprevent.org/
Guidance for healthcare providers, billing information, and instructions for patients/caregivers are available here: http://prescribetoprevent.org/about/
Opioid Medication Safety: The Role of Naloxone [video]
This 11-minute video presentation from Prevention Point Pittsburgh provides essential information for people who take opioids for pain and practitioners who are interested in prescribing naloxone as a safety measure when they prescribe opioids. This video provides easy-to-understand training for patients on opioid safety and how to use naloxone via IM and intranasal routes of administration. Access verified 3/16/2012.
Access video for viewing here: http://vimeo.com/37778160
Intranasal Naloxone for At-Home Opioid Rescue
By: Leavitt SB. Practical Pain Management. 2010(October);10(8):42-46.
PDF available for download: RescueNaloxone-PPM-Oct2010-Leavitt.pdf (420 KB; 5 pp)
Thousands of lives could potentially be saved each year from opioid overdose deaths if naloxone were more widely available and opioid-prescribed patients, their family caregivers, and other first responders were trained in its use. Intranasal administration provides a safe, effective overdose antidote, and this article identifies 15 groups of at-risk patients who could benefit. For unknown reasons, this seems to be a well-kept secret. Posted 10/23/2010.
Naloxone Prescribing Laws in the United States
Legality of Prescribing Take-Home Naloxone to Treat Opioid Overdose in the United States
From: Temple University, Beasley School of Law; Project on Harm Reduction in the Healthcare System.
Project website: http://www.temple.edu/lawschool/phrhcs/Naloxone/Naloxonepolicy.htm
50 States at a Glance: http://www.temple.edu/lawschool/phrhcs/Naloxone/50StatesNaloxone.pdf
State-by-State Summaries: http://www.temple.edu/lawschool/phrhcs/Naloxone/States.htm
This project assembles laws regarding the prescribing of naloxone throughout the United States. Naloxone, the standard treatment for opioid overdose, is a safe and effective prescription drug. High numbers of overdose deaths and evidence that witnesses to opioid overdose often do not know what to do and/or do not take appropriate action have motivated some public health authorities to institute programs that distribute naloxone directly to consumers. In such programs, opioid users, their family, friends, or others are instructed in overdose rescue techniques and provided a “take-home” dose of naloxone for administration in cases when medical help is not immediately available and/or while waiting for help to arrive. Some form of such naloxone prescribing is legal in all 50 United States. Accessed 9/2/11.
From: A consortium in the UK; updated continuously.
Website at: http://www.take-homenaloxone.org/
This is a website run by independent academics and healthcare professionals aimed at raising the awareness and profile of the use of take-home naloxone as a mechanism for reducing opioid-related deaths, and to provide a forum for discussing innovation, training, and practice developments. The site offers a number of important resources — articles, reports, training materials, etc. — addressing all aspects of using this antidote for opioid intoxication or poisoning. Access checked 10/18/2011.
Naloxone – Drug Information (Labeling Info)
From: Merck Manual / Lexi-Comp. August 2008.
HTML at: http://www.merck.com/mmpe/lexicomp/naloxone.html#N12AAE5
This authoritative document primarily offers information from the original labeling for Narcan®. Access checked 6/6/09.
Using Naloxone – Fast Facts (Palliative Care)
By: von Gunten CF, Ferris F, and Weissman DE. Fast Fact and Concept #39: Using Naloxone, 2nd Ed. 2009(Mar). End-of-Life Palliative Education Resource Center.
HTML document at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_039.htm
This document addresses special concerns regarding the management of suspected opioid overmedication and overdose in palliative care settings. Access checked 3/19/2013.
Naloxone for the Reversal of Opioid Adverse Effects
By: Marcia L. Buck, PharmD in Pediatr Pharm. 2002;8(8). Reproduced on Medscape, 2002.
HTML document at: http://www.medscape.com/viewarticle/441915
This brief article addresses the various applications of naloxone for countering adverse effects of opioids, including overmedication (intoxication), overdose, pruritus, constipation, and others. Access checked 6/6/09.
Intranasal Naloxone for Acute Opiate Overdose
From: Tim Wolfe, MD, and colleagues, regularly updated.
HTML documents at: http://intranasal.net/OpiateOverdose/
This site provides access to useful information on this topic, including links to published research articles of interest. NOTE: the intranasal administration of naloxone is currently an “off-label” application. Access checked 8/8/12.
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Clinical Tools for Assessing Opioid Risks
Properly validated and applied assessment tools can sometimes be useful for evaluating current or potential risks of drug abuse, misuse, addiction, or diversion associated with prescribed opioid analgesics for pain management. If properly interpreted, results may aid in determining appropriate opioid therapy, as well as in tailoring patient-specific monitoring regimens. However, use of the tools also requires added time for healthcare delivery and they are not intended to be used to denying any patients the most adequate treatment for pain relief.
The 10 assessment tools listed below are available for free download and use in clinical practice.
SOAPP® – Screener and Opioid Assessment for Patients in Pain
This questionnaire is available in 5, 14, and 24 question versions. It is intended to help facilitate assessment and planning of long-term opioid therapy for patients with chronic, and to help predict which patients might exhibit aberrant medication behaviors in the future. A tutorial on the use of SOAPP is provided, including an in-depth introduction, scoring instructions, and video case examples.
COMM™ – Current Opioid Misuse Measure
This 17-item, self-report questionnaire may help clinicians identify whether a patient, currently on long-term opioid therapy may be exhibiting aberrant behaviors associated with misuse of opioid analgesics. Since the COMM examines current behavior, it is ideal for helping clinicians to monitor patients during the course of therapy.
These 2 tools are available for download in English and Spanish-language versions at: http://www.painedu.org/soap.asp (Free registration required. Access checked 5/09/12)
From: Emerging Solutions in Pain (ESP)…
ORT – Opioid Risk Tool
This is a 5-item, yes/no self-report to help measure and predict a patient’s probability of displaying aberrant behaviors when prescribed opioid analgesia.
DAST – Drug Abuse Screening Test
A 28-item yes/no self-report for identifying patients with existing drug abuse or addiction problems.
DIRE – Diagnosis, Intractability, Risk, Efficacy
This is a clinician-rated, 7-item scale to screen for the appropriateness of long-term opioid therapy in patients with chronic noncancer pain, taking into account the likelihood of drug abuse, misuse, addiction, or drug diversion.
CAGE-AID – Cut down, Annoyed, Guilt, Eye-opener - Adapted to Include Drugs
A 4-item questionnaire developed for the quick screening of patients with possible alcohol or substance abuse problems. In many cases, a more specific and thorough tool should be used.
SISAP – Screening Instrument for Substance Abuse Potential
Five questions address concerns about alcohol, marijuana, and cigarette use in order to stratify patients with chronic noncancer pain according to potential risks of developing problematic behaviors during opioid therapy.
5-Point Prescription Opiate Abuse Checklist
This brief checklist is based on DSM-III-R parameters and was developed by a committee of pain management specialists. It is proposed as gauging the patient’s level of adherence to a current opioid analgesia regimen.
POSIT – Problem-Oriented Screening Instrument for Teenagers
This 138-item screening questionnaire was designed to identify problems and potential healthcare needs in 10 areas, including substance use/abuse, mental health concerns, and others.
Available for download at the ESP website: http://www.emergingsolutionsinpain.com/index.php?Itemid=242
Also, see more tools at: http://www.emergingsolutionsinpain.com/tools
(Free registration and login required. Access checked August 31, 2012)
Checklist for Adverse Effects, Function, and Opioid Dependence
This 1-page checklist from the "Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain" provides a concise list of follow-up assessment considerations in patients taking opioid pain relievers. The checklist includes common adverse effects, potential areas of functional concern, and signs of opioid dependence. Access verified 5/04/09
This checklist is available for download at:
Also see... Tools for Assessing Pain & Pain-Related Disability
Apart from opioid risks, a special section of this website has pain scales and checklists that are useful for clinically assessing how intensely patients are feeling pain and for monitoring the effectiveness of treatments at different points in time. These are variously designed for different age groups, as well as individuals who do not speak English and/or cannot verbalize responses.
Go to pain assessment tools section…>
Monitoring Opioid Adherence in Chronic Pain Patients: Tools, Techniques, and Utility
By: Laxmaiah Manchikanti, MD, et al. Pain Physician. 2008(March);11:S155-S180 (26pp).
PDF available at: http://www.painphysicianjournal.com/2008/april/2008;11;S155-S180.pdf
The prevalence of opioid misuse, abuse, and addiction has fostered considerable concern among physicians, who may subsequently hesitate to prescribe these medications. This paper provides a comprehensive overview of the numerous monitoring approaches that have been described in the literature – including screening instruments and urine drug testing – and it addresses the benefits and limitations of these techniques and tools.
The complex nature of drug misuse and abuse problems are discussed and, while no single monitoring technique can fully address these difficult issues, the authors describe how multiple approaches to adherence monitoring may be employed to sustain the prudent use of opioids for the treatment of chronic pain. Numerous charts and tables provide helpful summary information.
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Urine Drug Screening/Testing in Pain Management
The screening or testing of urine for both prescribed and unauthorized drugs can be an effective tool in clinical practice for the assessment and ongoing management of patients being considered for or currently managed with opioid analgesics for chronic pain. However, there are various approaches to such testing and it is not considered a substitute for good diagnostic skills. The several documents in this subsection provide helpful clinical guidance..
Urine Drug Testing: Current Recommendations and Best Practices
By: Owen GT, Burton AW, Schade CM, Passik S. Pain Physician. 2012;15(3S):ES119-ES133.
Available online at: http://www.painphysicianjournal.com/...15&page=ES119
Recommendations were developed by expert consensus of Texas Pain Society members and an examination of the best practices literature on urine drug testing (UDT). Risk management strategies for patients on opioid therapy and the rationale for the practice of UDT in pain care settings support the guidance provided. UDT is recommended as a tool to be used in concert with other assessment tools which, in addition to evaluative instruments like consent forms and pain questionnaires, are examined here. The authors explain important technical aspects of UDT and cautions regarding variations in laboratory or point-of-care testing. Access checked 12/27/12.
Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care
By: Douglas L. Gourlay, MD, FRCPC, FASAM; Howard A. Heit, MD, FACP, FASAM; Yale H. Caplan, PhD, D-ABFT; from Johns Hopkins University School of Medicine. 2012 (Ed 5); 24 pp. Supported by an educational grant from Purdue Pharma LP and Quest Diagnostics Inc.
Access PDF here: http://www.pharmacomgroup.com/udt/udt5.pdf
Urine drug testing (UDT) in clinical practice should be a consensual diagnostic test done for the benefit of the patient with pain. This CME course helps healthcare providers (1) understand the purpose of UDT and identify a clear testing strategy, (2) distinguish between UDT for detecting illicit drug use and for monitoring adherence to an analgesic treatment regimen, (3) appreciate drug-testing methodology, instrumentation, and sensitivity/specificity of results, (4) identify strategies to improve analysis and interpretation of results, and (5) understand the limitations of UDT. A discussion of unclear or confusing test results — positive or negative — includes current scientific understanding of possible medical explanations and interpretations. Advice on when and how to communicate with the testing laboratory or device manufacturer is also provided. Access update checked 9/18/12.
Interpretation of Urine Drug Testing in Pain Patients
By: Pesce A, West C, City KE, Strickland J. Pain Medicine. 2012;13:868-885.
PDF here: http://eorder.sheridan.com/3_0/display/index.php?flashprint=1970
(Requires Adobe Flash Player)
This paper reviews pertinent research literature and discusses 6 critical aspects of urine drug testing applicable to pain management practices: 1) which drugs and metabolites to test for, 2) which analytical cutoffs to use, 3) pain medication metabolism, 4) identification of alcohol use, 5) determination of patient compliance, and 6) which patient groups to consider for more frequent testing. Access checked 9/14/12.
Clinical Drug Testing in Primary Care – TAP32
From: U.S. SAMHSA/CSAT (Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment). 2012(May); 94 pp.
PDF here: http://kap.samhsa.gov/products/manuals/pdfs/TAP32.pdf
This Technical Assistance Publication (TAP) 32 is for clinical practitioners, such as physicians, nurse practitioners, and physician assistants, who provide primary care in office settings and community health centers. The publication provides information that practitioners need when deciding whether to introduce drug testing into their practices and gives guidance on implementing and interpreting drug testing. Access checked 5/25/2012.
Urine Drug Testing in Chronic Pain
By: Christo PJ, Manchikanti L, Ruan X, et al. Pain Physician. 2011;14(2):123-143.
PDF available at: http://www.painphysicianjournal.com/2011/march/2011;14;123-143.pdf
Medication-adherence monitoring is an important aspect of chronic pain management when prescribing controlled drugs. The authors review the history of urine drug testing (UDT) as well as the benefits and current limitations of the two primary types of UDT commonly used. Two useful sections include: 1) an algorithm designed specifically for monitoring patients taking opioids for chronic pain, and 2) a table that provides screening and confirmation cut-off concentrations plus urine detection time-frames for most controlled analgesic substances. This monograph includes discussions on the relevance of factors that affect urine testing, including human metabolic and drug pharmacokinetic principles, and drug cross-reactants. The section on the interpretation of results covers 5 potential testing outcomes. Access checked 7/19/11.
A Clinical Guide to Urine Drug Testing: Augmenting Pain Management & Enhancing Patient Care
By: Catherine A.Hammett-Stabler, PhD, DABCC, FACB and Lynn R.Webster,MD, FACPM, FASAM. From: University of Medicine & Dentistry of New Jersey, Center for Continuing & Outreach Education. 2008(May); 28 pp.
Access monograph at: http://ccoe.umdnj.edu/online/ARCHIVE/endurings/09MC07.pdf
This CME monograph (credit now expired) focuses on patient-centered Urine Drug Testing, UDT, used to enhance the management of chronic pain patients. In this context, UDT can serve as a useful tool to help verify patient-reported compliance or to demonstrate unreported drug exposure. Three key elements of UDT must be appreciated for its best use: 1) the pharmacologic characteristics of the drugs tested, 2) their relationship to the urine sample, and 3) the type of analyses performed by the laboratory.
Healthcare providers who order UDT should frequently consult with the laboratory to select appropriate tests and to keep informed of laboratory changes, such as adoption of new agents or assays. Practitioners should consider UDT results in the context of all the clinical information, and contact the laboratory to clarify test results when there is a discrepancy. This monograph provides necessary knowledge to interpret most UDT results within the context of pain management. Five case studies are included. Access verified 6/29/09.
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General Risk Minimization & Precautions
How to Avoid Opioid Misuse
By: Potter JS, Marino EN. Chronic Pain Perspectives. 2013;62(3):S2-S7.
Available online at: http://www.chronicpainperspectives.com/Article...How-to-avoid-opioid-misuse
The authors present techniques for reducing opioid misuse by building on the 2009 clinical guidelines for long-term opioid therapy in chronic noncancer pain that were developed by the American Pain Society and the American Academy of Pain Medicine. With the goal of encouraging clinicians to prescribe opioids for appropriate candidates experiencing moderate to severe chronic pain, they focus on risk evaluation for each individual patient. Additional strategies include the ongoing monitoring in patients prescribed opioids, utilization of prescription monitoring programs as needed, and other evidence-based strategies known to mitigate opioid misuse. A table contains practical recommendations to consider before treatment, during treatment, and when misuse requires opioid therapy termination. An additional table provides a list of risk assessment questionnaires and monitoring tools for long-term opioid therapy, both with links to web sources. Access checked 4/11/13.
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Use, Abuse, Misuse, and Disposal of Prescription Pain Medication Time Tool
From: American College of Preventive Medicine (ACPM), 2011.
Access documents here: http://www.acpm.org/?UseMisuse_Launch
The ACPM has developed Time Tools to provide physicians and clinical staff with evidence-based guidance to enhance knowledge and encourage preventive medicine services. Documents in this particular series address the provision of adequate pain control despite risks of abuse and misuse of prescription medications, and combined use of prescription with over-the-counter medications. Three separate Tools discuss vital information for practitioners as well as their patients on the safe use, prescribing, and disposal of opioid analgesics:
> Prescription Pain Medication Time Tool for Clinicians
> Prescription Pain Medication Clinical Reference
> Prescription Pain Medication Patient Guide
The ACPM acknowledges Purdue Pharma L.P. for its support of this resource through an unrestricted educational grant. Access checked September 25, 2011.
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Commonsense Opioid-Risk Management in Chronic Noncancer Pain: A Clinician’s Perspective
By: James D. Toombs, MD; from Pain Treatment Topics, August 2007.
PDF available here for download: http://www.pain-topics.org/pdf/OpioidRiskMgmt.pdf (145 KB, 13 pages)
Opioids have a legitimate and important role in treating chronic noncancer pain (CNP). Although there are risks, these medications should be available to patients who gain benefit from them and can use them safely. In this guidance paper, James Toombs, MD, applies the Model Policy for the Use of Controlled Substances for the Treatment of Pain from the Federation of State Medical Boards to provide a practical clinical framework helping to minimize risks when prescribing opioids. This allows standardizing the process of opioid management but does not dictate or constrain individualized approaches to therapy.
Recognizing potential risks of opioids, treatment decisions regarding their use should be made only after a comprehensive evaluation of patients. Due consideration should be given to the complete medical history, including past or potential substance misuse. Taking all factors into account, opioid selection, doses, and treatment monitoring can be effectively tailored for patient needs and prudent clinical practice. Access checked 4/28/09.
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Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners (Book)
By: Lynn R. Webster, MD, FACPM, FASAM, and Beth Dove; June 2007.
See review and ordering information at:
This book presents a balanced perspective in advocating effective pain control via opioid analgesics, when appropriate, yet cautioning the reader about the many associated risks and pitfalls. The authors point out that primary care physicians, nurse practitioners, and other first-contact clinicians are uniquely positioned to make a difference at the beginning of medical treatment. Patients with chronic pain or a substance-use disorder are more likely to seek treatment from a general practitioner than from a specialist. So front-line healthcare providers can maximize the chances for success when patients begin opioid therapy. The authors include step-by-step protocols for assessing patients’ risks of opioid abuse as well as for legally protecting the opioid prescriber. An emphasis is on acknowledging and addressing drug-related behaviors that sometimes compromise effective pain treatment with opioids. Access checked 4/28/09.
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Patient Level Opioid Risk Management
By: Nathaniel P. Katz, MD, MS; from PainEDU.org, Inflexxion, Inc., 2007.
PDF available for download at: http://www.painedu.com/manual.asp (1 MB, 39 pp; free registration required)
Opioids, like all medications, are associated with risks, and the prevalence of negative consequences of opioid use has risen concomitantly with their increased use. Risks include: abuse and addiction, overdose, side effects [eg, nausea, vomiting, itching, dizziness, sedation, cognitive dysfunction, mood disturbance, sweating, constipation], and endocrine disturbance. The risks of greatest concern have been abuse and addiction. While some clinicians have been comforted by a mythology that addiction does not occur in “legitimate” pain patients, the reality is that there is significant overlap between patients with pain and those with addictive disorders. In this document, the author discusses various myths and realities of long-term opioid therapy and offers guidance for risk minimization. Topics include patient risk assessment, management, and monitoring. Access checked 4/28/09.
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Assessing Obstructive Sleep Apnea Potential, Which May Affect Opioid Risk (Snore Score)
From: American Sleep Apnea Association.
PDF available at: http://www.sleepapnea.org/resources/.../snorescore
Patients with untreated obstructive sleep apnea (OSA) stop breathing repeatedly during sleep, sometimes hundreds of times during the night and often for a minute or longer. Besides other concerns with this disorder, persons with OSA who are prescribed opioid analgesics may be at particular risk of respiratory depression and fatal asphyxia. This quick, 6-item questionnaire – the Snore Score -- can help detect patients who have or are at risk for OSA, and thereby help guide better informed opioid-prescribing decisions. Accessed 7/25/11.
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Opioids for Pain: Risk Management (Module 6)
By: Steven Richeimer, MD; from California Society of Anesthesiologists; 2006.
HTML article at: http://www.csahq.org/cme2/course.module.php?course=3&module=12&terms=show
Pain management has become a medical-legal minefield. This brief CME program presents 8 preventative measures that can help reduce healthcare providers' risks of incurring a medical-legal action while providing effective pain relief for patients in need: 1) prescribe only to your patients; 2) assess pain thoroughly; 3) educate and provide informed consent; 4) document; 5) don’t hesitate to get help; 6) know how to manage addiction risk in patients with pain; 7) have a reliable emergency call system; and 8) don’t fail to treat pain. Access checked 4/28/09.
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Rapid-Onset Opioids: Recognizing and Preventing Abuse, Addiction, and Diversion
By: Lara K. Dhingra, PhD, and Steven D. Passik, PhD; from Medscape; 2006.
HTML article available online at: http://www.medscape.com/viewprogram/5471
Pain management requires a multidimensional approach to ensure safety as well as efficacy. Considering the potential growth of rapid-onset opioids in pain management, this brief CME course offers techniques for the recognition of addiction as well as aberrant drug-taking behavior. Various strategies and guidance are presented regarding therapeutic dosing and the use of rapid-onset opioids for breakthrough pain. Two important practices are discussed: 1) thorough prescreening of patients, and 2) the clinician’s responsibility to monitor treatment compliance. Access checked 4/28/09.
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Universal Precautions in Pain Medicine:
The Treatment of Chronic Pain With or Without the Disease of Addiction
By: Douglas L. Gourlay, MD and Howard A. Heit, MD, in Medscape Neurology & Neurosurgery, 7(1), 2005.
Similarly published in Pain Medicine, 6(2), 2005.
HTML article available online at: http://www.medscape.com/viewarticle/503596
It is impossible to determine before hand, with any certainty, who will become problematic users of prescription opioid medications. With this in mind, the authors stress the need to carefully assess all patients regarding past and present aberrant behaviors when they exist, and to apply reasonably set limits in the clinician-patient relationship. Along with this, it is possible to triage chronic pain patients into one of three categories according to risk.
By adopting a "universal precautions approach" to the management of all chronic pain patients, regardless of pharmacologic status, stigma is reduced, patient care is improved, and overall risk is contained. Careful application of this approach will greatly assist in the identification and interpretation of aberrant behaviors and, where they exist, the diagnosis of underlying addictive disorders. Treatment plans can then be adjusted on an individual basis, as described in this article. Access checked 4/28/09.
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Treating Pain and Preventing Abuse and Diversion
By: Brian Goldman, MD, MCFP, FACEP, from LearnSomething.com, 2005.
Go to online course...> (Click on "Click here to begin registration"; free registration is required.)
Both the under-treatment of pain and opioid drug abuse are serious problems in our society. The Food and Drug Administration (FDA) and the Drug Enforcement Administration (DEA) have recommended that the makers of scheduled opioid analgesics develop Risk Management Programs (RMPs) that address abuse and diversion. One of the key parts of the RMP is an educational program "assuring the safe prescribing of the product by physicians."
The aim of this continuing medical educational (CME) course is to minimize and prevent prescription drug diversion by helping physicians recognize the principles of good pain management and, at the same time, to recognize patients at risk of abuse, addiction, and diversion of opioid analgesics. Included discussions will help readers identify the “street” market for opioid analgesics, understand methods used by criminal drug diverters, and design strategies to minimize drug diversion without harming legitimate patients. Access checked 4/28/09.
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Opioid Risk Management - THCI Conference Presentations
From: Tufts Health Care Institute, 2005.
Go to website at: http://www.thci.org/opioid/
In March 2005, leading experts from industry, academia, and regulatory agencies gathered in Boston to discuss current thinking and future directions in opioid risk management. The conference, chaired by Nathaniel Katz, MD, MS, of Tufts University School of Medicine, addressed issues surrounding the abuse of prescription opioid analgesics.
It was recognized that abuse of Rx opioids has become a major problem in the U.S.-- ahead of cocaine, heroin, and stimulants -- and the pharmaceutical industry is subject to increasing pressures by the FDA, DEA, Congress, and the general public to minimize the risks associated with their opioid products. The one-day, invitation-only Opioid Risk Management conference featured 15 presentations of the latest information on these challenging issues, which are available for download and viewing at the Tufts Health Care Institute website. Access checked 4/28/09.
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Also See: Pain-Topics.org "Addiction & Pain Treatment" Section
This special section focuses on the clarification, identification, prevention, and treatment of addictive disorders within the context of pain and, conversely, on pain management in persons with a history of addiction. Patients in pain may misuse a variety of substances to palliate their conditions, including prescribed and illicit opioids. Continued misuse can become harmful abuse, which may lead to physiological and psychological dependence (addiction). The interface of pain and addiction is a common and vexing problem in clinical practice.
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