The use of chronic opioid therapy — the use of opioids daily for a minimum period of 90 days — has increased tremendously over the years, with a recent surge domestically in the past few years.
Opioids have long been used for treating terminal pain, like cancer. Then, they slowly were used to treat non-terminal pain, and today it’s estimated that opioids are now used by 3 percent of primary care patients for pain.
Oftentimes patients using chronic opioid therapy for pain will encounter acute pain, from either a medical procedure or an accident. Acute pain can also stem from using opioids that are not prescribed — many that receive chronic opioid maintenance therapy in an effort to combat addiction will seek out illegal opioids.
Using opioids to manage pain in those that problematically use is to prevent complete withdrawal, which can lead to more complications. Dosing down helps to gradually reduce the addiction, and this is a more efficient way to prevent a possible relapse, making the addiction even stronger.
Managing pain when there is chronic opioid use disorder present requires a very calculated plan. It begins with a thorough initial evaluation of the patient, where past opioid use as well as their complete medical history, including injuries, accidents and surgeries, are taken into consideration.
The initial evaluation process of an individual experiencing pain with chronic opioid use disorder in an in-depth review of their opioid use history, complete with full medical records, while performing diagnostic tests to determine whether or not the situation is a worsening of the current issue or a new pain.
Is the patient truly experiencing a new pain that requires attention — or is the pain an amplification of the current situation. It’s important to properly identify and diagnose this in order to create an effective strategy to help the patient, with his or her best interest in mind.
Sometimes a patient who is receiving therapy for chronic opioid use will experience additional pain because of a drug interaction. What this does, in this situation, is lower the effectiveness of the current pain management plan in place, spark a new medical condition, as well as contribute to increased tolerance of the opioid.
In addition, the actual underlying medical condition or disease can progressively get worse, leading to increased pain as well.
There are also several psychological aspects to consider, as they will often play a direct role as well. This is why it’s so important to properly and thoroughly screen chronic opioid therapy patients for psychiatric disorders. Doing so can help to properly treat the patient more effectively in a safer manner. The more information pertaining to each patient available — and at the clinic’s disposal — the better.
When treating pain in people with chronic opioid use disorder there is a specific set of steps that must be followed to prescribe pain medication — and they are designed specifically to treat those with chronic opioid use disorder.
It’s important to point out that this three-step process is for those who are using opioid analgesics for pain, and not using opioid substitution therapy for addiction. Also, this does not apply to addicts — opioids or heroin.
The original, long-acting opioid should be continued by the patient in the best case scenario. Also, oral delivery is preferred, unless the patient is physically unable to swallow medication. In that event, an IV dose can be administered. Some patients also have a difficult time absorbing the opioid in pill form, and in that case intravenous delivery is a better option.
The opioid that is being used for the current pain management is also the preferred choice for the chronic opioid use disorder. For example, if the patient currently takes an oral dose for pain management, an oral dose of the short-acting opioid is suggested. Doing so reduces the risk of any potential side effects from a different kind of delivery mechanism or opioid.
There are a few reasons why treatment using intermittent opioids is more effective, with two main reasons. First, it gives the treatment staff more flexibility when it comes to when the dosage can be administered, and second, it lowers the cost, as it’s not as frequent.
Intermittent opioids are the best for patients that need a rapid dose or cannot manage Patient Controlled Analgesia — this is the safer alternative.
There are also studies that suggest the use of intravenous opioids in this manner not only provide proper pain relief in under twenty-four hours, but also avoid potential pitfalls, like respiratory depression.
Since there are many variables that come into play, it is impossible to develop a cookie-cutter dosing strategy. But, it’s safe to say that it’s generally effective and one that clinics often explore.
Opioid sparing strategies are used to lower the side effects of opioids and lower the risk of hyperalgesia as well as building tolerance.
When managing pain in people with chronic opioid use disorder, it’s common for them to experience more pain that is uncontrolled, compared to people that do not have an opioid use disorder.
It’s also important to note that these people will often have acute pain resulting from a disease or an injury, which also require treatment. Since the tolerance level is typically high due to the opioid use disorder, the dosage will often need to be higher, thus requiring additional supervision and ongoing maintenance to prevent substance abuse.
There are two main opioids commonly used to manage pain in people with chronic opioid use disorder — buprenorphine and methadone. There are a couple of important things to know about these two opioids. First, the analgesic effects last up to eight hours and second, and because of that, they are dosed daily.
When using methadone to manage pain in people with chronic opioid use disorder, it’s typically dosed somewhere between 80 and 120 mg on a daily basis. In some situations the dose can be higher, depending on additional opioid usage and tolerance levels.
Buprenorphine will sometimes reduce the effectiveness of other opioids, and this is due to it having a high affinity for opioid receptors. Patients on buprenorphine typically will not have to stop usage due to acute pain management.
While most clinics will use methadone and buprenorphine to manage pain in people with chronic opioid use disorder, there is also an increased use of naltrexone recently, because of its ability to block opioid agonists for up to three full days. Because of this, it’s expected that more experts will begin to monitor its results and effectiveness as an alternative to the more common opioids — methadone and buprenorphine.
When it comes to managing pain in people with chronic opioid use disorder it’s important that their entire situation is evaluated thoroughly — including current physical condition, medical history and the source and or cause of new pain. From this point, the specific condition needs to be treated.
An extensive initial assessment along with a well-thought out plan of action is instrumental in managing pain in people with chronic opioid use disorder — something all reputable clinics and treatment facilities implement.
Dr. Vikram Tarugu, M.D, is the CEO of Detox of South Florida, Inc and medical professional focused on addiction. A veteran in the medical field with over 25 years of professional experience. He is a consultant for many South Florida Rehab centers. Patients travel from allover the US to seek his help with addiction and Hepatitis C treatment.
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