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If you’ve taken opiates for more than 5 days, your body is already dependent on them quitting them requires a medical detox, not just a taper protocol.

INFORMATION FOR CHRONIC PAIN MANAGEMENT PROVIDERS

You patient wants to move to non-opioid pain management

Some patient will request to discontinue opioid pain management. The best candidates for this are motivated patients. These patients could also be experiencing hyperalgesia, declining function on opioids, polypharmacy or simply the underlying pain issue may be resolved. Motivated patients may response very well to a traditional 10% per week taper, while others may have physical detox difficulties which prevents them from following your taper instructions. Those with difficulties may be excellent candidates for a Buprenorphine taper.

 

Your patient must be on a reduced dose before surgery

Surgical providers often need to reduce a patient's opioid use prior to surgery. Many surgeries are postponed indefinitely because the patient cannot reduce use prior to surgery on their own. This leaves the patient in a place where they are unable to take the next steps in their treatment and leaving them on perpetual opioid pain management. 

 

Your patient is experiencing hyperalgesia

Opioid-induced hyperalgesia is another common problem providers face. Not only is hyperalgesia difficult to diagnose, but it also closely resembles both drug tolerance and drug withdrawals leading the patient to assume they need more opioids. This is frustrating to the provider and the patient. Use of patient detox can assist the patient to stop the opioid use and attempt alternative therapies for pain management.

 

Your patient is misusing prescribed medications.

Patients can begin to misuse prescription medication. As you may know, there are many ways to identify this behavior.

 

Here a few tips to identify those patients:

  1. Communication and full team involvement – A patient with pain should show outward signs in the parking lots, front office, halls and in the treatment room. Talking about identifying behaviors with all staff can be a critical step to identifying if misuse is occurring.
  2. Look at the patient’s behavior – Are they obsessive and impatient with staff? Do they excessively flatter staff? Do they keep follow up appointments, or do you only see them when they need a refill? Are they requesting adjuvants to pain management? Is there polysubstance abuse?
  3. Make sure you have good understanding of the patient’s history – Do you really understand the mechanism of injury? Many times patients will mislead physicians on the severity of the injury. If a patient is suspected of misuse, you should look for  inconsistencies in the patient's story.
  4. Does your examination line up with the patients reports of pain? One technique is to palpate a non-injured area while also gently palpating an injured area. Another is to move smoothly between the different components of the exam without giving the patient sufficient time to react to each one.
  5. Testing prior to entering the treatment room – As you already know regular toxicology testing is critical. Testing is patients who are not coming to regular appointments is a must. It is recommended toxicology screening is done prior to entering the treatment room. This prepares the provider to use the time with the patient to screen using other techniques for misuse.
  6. Offer alternatives – Is your patient open to other pain relief plans? Patients unwilling to attempt alternative therapies may raise red flags.

 

You have patients that no longer need pain management

 

When the treatment team deems it appropriate to taper a patient off of opioids, the Patients must also be motivated to reduce tapering. A good rule of thumb to taper a patient is to reduce the use by 10-20% per weeks. The difficulty with this is the patient still has the prescription, and may not be compliant to the taper schedule. It also can be a long taper for some patients. This can lead to follow up appointments, where the patient comes back seeking a refill and states the taper was too difficult. Buprenorphine is an excellent alternative in tapering opioids. Studies have suggested that use of buprenorphine transitioned from other opioids for pain control have improved pain control, improved psychiatric symptoms, and as mentioned, a lower risk of overdose and death. RMD can partner with you to assist your patient in a Buprenorphine taper.

DETOX PRE-SURGERY

Frequently when a patient is in chronic pain, their MME is too high for surgery and/or to handle breakthrough pain. Detoxing the patient off opioids or to a lower dose can sometimes be medically necessary and beneficial to improve outcomes.

Effect of Preoperative Opioid Use on Adverse Outcomes, Medical Spending, and Persistent Opioid Use Following Elective Total Joint Arthroplasty in the United States

Between 17% and 40% of patients undergoing elective arthroplasty are preoperative opioid users.

Among 34,792 patients (38% hip, 58% knee, 4% shoulder), 6,043 (17.4%) were preoperative opioid users with a median morphine equivalent daily dose of 32 mg. Preoperative opioid users had increased length of stay (IRR = 1.03, 95% CI = 1.02 to 1.05), nonhome discharge (OR = 1.10, 95% CI = 1.00 to 1.21), and 30-day unplanned readmission (OR = 1.43, 95% CI = 1.17 to 1.74); experienced 35% higher surgical site infection (HR = 1.35, 95% CI = 1.14 to 1.59) and 44% higher surgical revision (HR = 1.44, 95% CI = 1.21 to 1.71); had a median $1,084 (95% CI = $833 to $1334) increase in medical spend during the 365 days after discharge; and had a 64% lower rate of opioid cessation (HR = 0.34, 95% CI = 0.33 to 0.35) compared with patients not filling two or more prescriptions across periods.

Preoperative opioid users had longer length of stay, increased revision rates, higher spend, and persistent opioid use, which worsened with dose. Adverse outcomes after elective joint replacement may be reduced if preoperative opioid risk is managed through increased monitoring or opioid cessation. Source

Preoperative Chronic Opioid Therapy
A Risk Factor for Complications, Readmission, Continued Opioid Use and Increased Costs After One- and Two-Level Posterior Lumbar Fusion -  Source

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