Pub. 3 2019 Issue 2

Protect Your Patients D ear Colleagues, Providers, and Professionals: Patients receiving chronic opioid analgesic therapy who have abruptly lost access to their prescriber (e.g., as a result of a clinic closure) are at immediate risk of withdrawal, and consequently, over- dose and death from opioids obtained from non-medical sources. 1 While national guidelines recommend clinicians avoid increasing an opioid dosage to 90 MME daily, there is little evidence about the benefits and harms of abruptly reducing high dosages of opioids in patients who are main- tained on high doses of opioid analgesics. To reduce morbidity and mortality from abrupt loss of opioid analgesic treatment among patients on chronic opioid therapy for whom you assume care, the Utah Department of Health Violence and Injury Prevention Program recommends :2, 3 1. Do not abruptly discontinue or taper opioids. • Do not dismiss patients from care. Abrupt discharge from care can adversely affect patient safety and can result in missed opportunities to provide potentially life-saving information and treatment. • Discuss with patients the benefits and risks of con- tinued opioid therapy, including potential benefits of tapering dosages and/or addiction treatment if patients met the criteria for opioid use disorder. 2. For patients who agree to taper their dose, col- laborate on a taper plan, maximize non-opioid approaches to pain management, and taper slowly enough to minimize withdrawal symptoms. • Patients maintained on chronic opioid therapy for years will likely need to slowly taper their medication (e.g., 10% per month, but the pace of tapering should be individualized). • For resources on how you can support your patient’s wellbeing, visit Opidemic.org’s provider page. . 3. Closely monitor and mitigate overdose risk for patients who continue to take opioids. • Risk mitigation strategies include: o Co-prescribe or dispense naloxone and train patients and family members on naloxone administration. o Counsel patients to avoid mixing opioids with alcohol, benzodiazepines, or other central nervous system depressants. o Consult with patients’ other care providers to limit co-prescribing of benzodiazepines. o Maximize non-opioid pain management strategies. • Provide the online Naloxone training to your patients, and encourage them to purchase a naloxone kit with the standing order next time they are at their local pharmacy. 4. Offer or arrange medication for addiction treat- ment with buprenorphine or methadone for patients with a diagnosis of opioid use disorder. • DSM-5-defined opioid use disorder is a problematic pattern of opioid use leading to functional impair- ment; 4 physiological dependence on opioids alone does not indicate opioid use disorder. • If patients met DSM-5 criteria for opioid use disorder: o Communicate your concern for their safety andwell-being. o Avoid abrupt opioid discontinuation. o Offer or arrange for evidence-based treatment that includes FDA-approved medication, such as bu- prenorphine or methadone. 5. Attend a Comagine opioid safety training and learn how to safely prescribe opioid medications for your patients. For patients in your current panel, prescribe opioids judiciously to prevent or reduce future risk of high- dose chronic opioid use. Concurrently, adopt this guidance for patients you assume are already on high- dose chronic opioid therapy and maximize the use of physical, psychological, and multimodal pain therapies. These practices will help mitigate the risk of addiction, overdose, or even death to patients and help stop the opioid overdose crisis in Utah. 1 U.S. Food and Drug Administration FDA Drug Safety Communica- tion. April 9, 2019. Accessed Aug. 19, 2019. https://www.fda.gov/drugs/ drug-safety-and-availability/fda-identifies-harm-reported-sudden- discontinuation-opioid-pain-medicines-and-requires-label-changes. 2 Dowell, Deborah. CDC Guideline for prescribing opioids for chronic pain. 3 Dowell, Deborah. No Shortcuts to Safer Opioid Prescribing, New England Journal of Medicine. 4 American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorder, Fifth Addition [Book]. Arlington, Virginia: American Psychiatric Association, 2013. By Utah Department of Health Violence and Injury Prevention Program 31 |