Complete Your CE Test Online - Click Here oral ER/LA opioids should not be broken, chewed, or crushed, and patches should not be cut or torn prior to use, since this may lead to rapid release of the opioid and could cause overdose or death. Prescribers should educate themselves about the general characteristics, toxicities, and drug interactions for long-acting opioid products. Respiratory depression is the most serious adverse effect of opioids as it can be immediately life-threatening. The risk of respiratory depression or respiratory arrest is higher in patients with an upper respiratory infection, asthma, or other respiratory problem, hence, if these conditions arise, the opioid dose needs to be reduced. Constipation is the most common long-term side effect, but it can often be managed. Drug-drug interaction profiles vary among the products. Knowledge of particular opioid-drug interactions, and the underlying pharmacokinetic and pharmacodynamic mechanisms, allows for the safer administration of opioid analgesics. Central nervous system (CNS) depressants (sedatives, hypnotics, tranquilizers, tricyclic antidepressants, and alcohol) can have a potential effect on sedation and respiratory depression due to opioids. Alcohol consumption should be avoided entirely with some oral products (e.g., morphine, hydromorphone, oxymorphone) because ethanol increases the plasma concentration of the opioid. Opioids may enhance the neuromuscular blocking action of skeletal relaxants and produce an increased degree of respiratory depression. Using opioids with monoamine oxidase inhibitors (MAOIs) may result in an increase in confusion, anxiety, and respiratory depression. Opioids can reduce the efficacy of some diuretics by inducing the release of antidiuretic hormone (ADH). In addition, some opioids interact with various cytochrome P450 enzyme inhibitors and inducers and, thus, may result in higher or lower than expected blood levels of the drug. Methadone can be an effective opioid, but it must be prescribed carefully and with full knowledge of its highly variable pharmacokinetics and pharmacodynamics. 3. Treatment plan. A written treatment plan should state goals that will be used to determine treatment success, such as resolution of the condition, healing of an injury, pain relief, and/or improved physical and psychosocial function. The plan should also indicate if any further diagnostic evaluations or other treatments are planned. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient, and goals should be reassessed at each office visit. Other treatment modalities or a rehabilitation program may be needed depending on the etiology of the condition and the extent to which the condition is associated with physical and psychosocial impairment. Nursing consideration: Nurses must be active participants as the healthcare team (including the patient and family) works to develop an effective treatment plan. 4. Informed consent and agreement for treatment. Health care providers should discuss the risks and benefits of the use of any controlled substances with the patient, persons designated by the patient, or with the patient’s surrogate or guardian if the patient is unable to make their own medical decisions. The patient should receive prescriptions from one physician and one pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written patient/provider agreement outlining the patient’s responsibilities, including: ○ ○ Urine/serum medication levels screening when requested. ○ ○ Number and frequency of all prescription refills. ○ ○ Reasons for which drug therapy may be discontinued (e.g., violation of agreement). 5. Periodic review. Health care providers should periodically review the course of treatment and any new information about the etiology of the illness, injury, or condition. Continuation or modification of controlled substance treatment depends on the physician’s evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by resolution of symptoms, healing of injury, decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient’s response to treatment. Monitoring high- risk patients through drug testing or pill counts may be necessary to assess adherence to the treatment regimen. If the patient’s progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. Using prescription drug monitoring programs (PDMPs) PDMPs can serve an important clinical monitoring role. PDMPs use secure Internet sites to offer point-of-care access to records of controlled substances from other prescribers and dispensing pharmacies. From these, clinicians can quickly glean patterns of prescription drug use that can be helpful in confirming or refuting suspicions of aberrant behaviors. Information from a PDMP may also be clinically relevant in that it may reveal that a patient is being prescribed medications whose combinations are contraindicated. Registering for and using the West Virginia Controlled Substance Monitoring Program will allow clinicians to get a sense of the controlled substances that the patient has been receiving from other prescribers and pharmacies. Individuals may have perfectly acceptable reasons for multiple prescribing episodes, but the existence of such a pattern should always trigger inquiry. Nursing consideration: Nurses must promote and perform periodic evaluation of patient progress and help to revise the treatment plan as needed. 6. Consultation. Health care providers should be willing to refer the patient as necessary for additional evaluation and treatment to achieve treatment objectives. Special attention should be given to those patients who are at risk for medication misuse, abuse, or diversion. The management of patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation, and consultation with or referral to an expert in the management of such patients. 7. Medical records. As noted previously, and as required by the CSA, health care providers must keep accurate and complete records, which should include the following: ○ ○ Medical history and physical exam. ○ ○ Diagnostic, therapeutic, and laboratory results. ○ ○ Evaluations and consultations. ○ ○ Treatment objectives. ○ ○ Discussion of risks and benefits. ○ ○ Informed consent. ○ ○ Treatments. ○ ○ All medications (including date, type, dosage, and quantity prescribed). ○ ○ Instructions and agreements. ○ ○ Periodic reviews. 8. Termination of treatment. A critical component of any treatment plan is a description of how treatment with an opioid medication might be terminated. Stopping opioid therapy in cases of chronic non-cancer pain is often more difficult than starting it. Being clear about the conditions under which opioid therapy will end is important because opioids are not curative, have no standard duration of treatment, and may be associated with substantial risks [17]. Termination may be required for many reasons, including: ○ ○ Healing or resolution of a specific pathology underlying the pain. ○ ○ The experience of intolerable side effects. ○ ○ Lack of adequate response to a medication in terms of either pain relief or functional improvement. ○ ○ Evidence of non-medical or inappropriate use of the medication(s). If inappropriate use of a prescription medication is discovered, treatment should be suspended, although provisions should be in place for continuation of some kind of pain treatment and/or referral Page 6