Safe prescribing of opioids for non-cancer pain z ichael MeDonough rector SUMMARY dciction Medicing and ; ricoloay ‘judicious approach in considering op estern Hospital therapy and choosing an appropriate op elboume is needed. a After an initial opioid trial, therapy sho 2y Words ae only be continued when there is reasonal stance use cisorder ‘evidence that itis effective and safe. The evidence for harm associated with it Prescr 2012585:20-4 long-term opioid prescribing is mounting while there is itle evidence to support long-term efficacy. In many cases, reducing and eventually stopping opioid therapy be the best course of action, Commitment by both the prescriber and the Patient to a treatment plan which includes: regular reviews is essential if opioid therapy is prolonged. Introduction ‘The prevalence of opioid prescribing in Australia, particulary for persistent non-malignant pain, nas bbeen steadily increasing! There is emerging evidence (of a corresponding increase in deaths where opioids ‘were detected? Similar trends have been reported in the USA with an alarming escalation in opioid-related deaths: Safe opicid prescribing is best defined by the principles for the quality use of medicines in Australia’s National Mecicines Policy.‘ This recommends that ‘any reason to prescribe needs to be considered judiciously then appraised for appropriateness, and thereafter monitored for safety and efficacy. State legislation ‘To prescribe opioids beyond eight weeks, mast states and territories require the prescriber to have a stat= permit, However in NSW, a permit is only needed for prescribing opioids to patents with drug dependeno=: Allotherjursdctions ned to berated forary -SESSNSES=S centres sic selies for palient whe srg dependent merapeg creme nommaigrart co Considering opioid treatment ‘Relative contraincicatons There site evidence fr the efficacy of one-term TIS SH memeneus carmeccstons to opioid opioid use in persistent non-malignant pain angin «TMS Sf Gevelapieg sacks Genendence during trials (upto three months) many patients experiences (SOST=™ SEG saslaesc essing in some adverse drug effects.’ However, there is expert nie eee eee. for exorple iy the risk for Screening compliance | Full toxtfroe online at www.australianprescelber:comSES rEERUARY 202 [gf scbstance use disorder. To {Sependence, consult with a pain or Gime specialist when a patient develops J Sesking 3 dose increase, particularly ‘opicid-related behaviours {Setneed to be considered when iSstert clude the folowing: Selerated opioid treatment ‘ectertal interactions, e.g. tramadol sserctonergie drugs such as selective Se fectske inhibitors can cause serotonin ASE E— previous intentional overdoses Igeste-ossophageal refx disease or jestrontestinal hypornotilty Se SSIs © renal impairment may result in orphine scouruation other exstng consitions, e.g. many patients with porohyrs have sensitivity to several opioids loccusstons €5. patients working in the ‘aviation or mining industry and other situations “that impose zero tolerance for any drugs of dependence an appropriate opioid jppropriste opioid best avoids the risk of drug factions, isease interactions and patient actions’ (for example patients may favour jperresistant’ options if children are at home). long-acting opioids are recommended because (acting opioids wear off quickly (particularly {plerance overtime), require frequent repeat ing 2nd, Fused chronically, may cause ‘analgesic Bund! or break-through pein. Long-acting isdetmal snd sublingual opioid formulations might onsidered for patients who have problems with lowing tablets. ents with drug dependence stronaly prefer short- 9 drugs with faster onset of action and with 1 Deak blood levels (that is, quick reward). They often state s preference for immeciate-release baations or resist taking long-acting drugs. Chronic use of injectable drugs is inappropriate persistent pain because recurrent injections lead fesue injury (which reduces drug absorption), Fy the risk of infection as @ consequence of injecting and have 2 greater risk for addiction | diversion”. People who are drug dependent Box Trialling opioids in F ‘Assess the potential merits and contraincications for opioid in patients unresponsive tocother Tirstiine' treatments Consider whether depressions a complication and needs treatment before proceeding with a trial of opioids Formulate a treatment plan for the next month which the patient aarees to Include ‘weekly reviews and explain the possibilty that treatment may not prove helpful and ‘may need to be discontinued. Have the patient fillin a Brief Pain Inventory. Start treatment with a long-acting opioid of moderate efficacy Recommend the patient keep a daly diary to monitor activites and pain-related impairment Ensure the opioids will be safely stored in the home and secure from children Establish a dalogue with the pharmacist Review the patient weekly witha family member and the patient's diary. Appraise treatment efficacy with Brief Pain Inventory and witness accounts (family members, [Pharmacist Ifthe patient has a poor response, consider a dose change. If they are tunable to tolerate treatment, consider switching to an alternative opioid stating ata low dose. Monitor for adverse effects (¢.9, developing constipation, sleep problems, drowsiness, miosis, slurred speech) Recommend the patient voids driving until further assessment oftheir opioid therapy. Consider baseline Epworth Sleepiness Scale (ESS) to assess possibie {daytime somnolence. Ask the spouse about any current snoring or sleep problems (opicids may increase these conditions when taken at night). typically manifesta very strong preference for their drug of choice and such patients can be remarkably convincing in ther efforts to persuade a compassionate doctor that such therapy isthe only effective treatment. Pethidine is now generally Viewed as a poor opioid analgesic in comparison with ‘most others now available and is inappropriate for persistent pain.® Patient reports of ‘drug allergy’ might instead be dose-related adverse effects lke nausea or pruritis ‘and therefore dose reduction is suggested rathar than avoidance, or referral to clinical immunology for specific drug sensitivity testing. Sometimes the latter may be necessary if options are restricted by the patient reporting ‘lleray’ to muiile opiokds particularly if there is strong patient preference for treatment with a specific drug, for example pethidine. Evaluating the efficacy of ongoing opioid therapy After a successful intial therapeutic tril, continuing ‘opioid treatment requires commitment to a treatment plan of regular reviews of efficacy and safety. 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az0w Sj] JUBLUSAOUdUIL JeuoHsuNy YUM Adesayy Ploido Buyjeje10Dible 1 Managing opioid-induced adverse effects © ADVERSE EFFECT astrointestinal Nausea and vomiting Chronic constipation and related sequelae including {abdominal pain, reflux haemorrholds, colonic hypomotity Reciced saivary Flow posing dental problems Gastro-cesophagea! reflux cisease DNerscseal frvaed option _.- Seaton Saal cil yperoacnacia ed scons) -_ E coorll cl Donen -_— Respiratory deoression SS a Poloned Oe Eo Bo sorta deticon = Other bale: Fhig tenon ane ores ‘occupations and cng mnpaiment SUGGESTED STRATEGY Reduce dose, consider alternate formulation (sublingual, transdermal), exclude chronic constipation Recommend regular bulking agent, extra lids, nan-osmotic axatves ‘Shcmonthiy dentist reviews, brushing an flossing teeth, extra furide treatment, encouragesge salivary low after meals, diet ‘pectic treatment eg. proton pump inhibitor such as omeprazole Consider reducing oF stopping onioids Periodic assessment, min-mental state examination Heel-toe galt testing Consider monitoring with Epworth Sleepiness Scale (for excessive daytime sorsnolence) and ith fay and other witness accounts (e9. pharmacist) Consider possllity of drug interaction (2. benzodiazepines) and review dosages and need Periodic assesement, avoid doses >120 mg (mg morphine equvelent) Monitor prolactin Monitor testosterone Montor tom baseline, check vitamin D status, eek specialist guddanco Conse respiatory physician [ty conmsinicaton (eg methadone), reduce dose sleep study (polysomnograpty), const respiration ohyscan Especaty in patents mic type 2 respiratory talure (CO, retention) and those on home onge Dewy Deterioration requires specialist intervention and probable opioid discontinuation ‘Secrocancioaram (Gersctarty wah methadone and cxycodone) Montor fom baseline. reduce dase and review (Consult acciction specisist conser referral to methadone program ‘Prescribe small amounts (e- weekly supp). ensure only one prescriber and likewise Pharmacist. assess patot for depression Document, reduce dose. rest soci, considera diuretic Estcolsh baseline nc resem with reference to reliable co-nformants Diversion potent (Conscer tamper sesctane prensrations require patent to have secure storage (eg. lacked ctl x), deerate one pharmacy, note on scrint, fax script in advance Prescbers con ales check with the Prescription Shopping Information Service (rirm mesicareavatrsia oon au/orovider/pbs/prescrition-shopping/index so#NI0058) REFERENCES 1 Leongh, MunonE MaSePS 2 eau AC DoE S SRSEAS Valco, caret), 4 National meccines Pot. auatty| Eamraton o'coocprescbeg Drummer Oh Canna Smith Geecry 2. Mecorhy igen MA, Use of Medicines. Department of in Australi or as 2 oases Ses neers ‘Blow FC Assocation between Heath ad Ageing. 1598 Inter Med | 2005 S37 Seroere ewe ale ‘sped prescribing patterns and ‘win ealth gov a/intemet many BOPHOR me TPES —— apod overdose related deaths publishing nst/Conten/nmo- Be EET ‘Quality tm feted 2012 Jan 6)