When monitoring methadone, should we look for different Qtc intervals for men & women?
No, the more important information is a history of cardiac disease and other risk factors for arrhythmias such as thyroid disease.
How do you taper/discontinue patients with aberrant behavior, dependency, or addiction?
Patients with addiction need referral to a SUD treatment program and are not likely to follow your instructions for an outpatient taper. Patients who are not addicted but cannot comply with opioid therapy should be tapered by 10-20% every 3-7 days depending on the urgency of completing the taper.
When is it appropriate to refer to a pain specialist?
When you need confirmation that your plan of care is right for your patient you can refer a patient to a pain specialist. If you have a patient with low back pain that is radicular in nature you can refer the pain to an anesthesia pain specialist for evaluation for a epidural steroid injection to help reduce the pain.
Which urine drug screen is suggested? How long are opioids still found in UDT after use?
The basic urine screen is recommended and most commonly used. You can use the gas chromatography UDT for confirmation or rule out if you are looking for a specific medications or suspect diversion.
This will vary with a number of factors such as dose, duration of use, liver/renal function, and the individual lab and test being performed but approximately 1 week is a good rule of thumb.
Would opioid rotation be effective for treatment of opioid resistant dyspnea?
There is no specific opioid that is best for any specific symptom. Usually other patient-specific factors such as underlying disease, past medication use, and ability to tolerate oral vs.other routes of administration will determine the choice.
If during change from one opioid to another, the patient experiences withdrawal symptoms, how do you manage? Increase dose of new med or some other method?
When you are rotating a patient from one long acting opioid to another you will need to provide adequate breakthrough medication to reduce the risk of withdrawal.
Do you do sleep studies before initiating therapy for pain management?
Not routinely. Only for obvious risk factors and signs of a sleep disorder, which usually requires collateral information from the bed partner.
Is it okay to stop low dose ER opioid if used only for 5 days (Example OxyContin 10 mg BID X 5 days) without tapering. Also taking IR for BTP (Post-surgical patients)
I usually tell the patient to taper by stopping one dose at a time. So perhaps BID x three days then once daily for three days. You can stop it without tapering but the patients will need adequate breakthrough meds.
Is it okay to use short acting opioids for pain and antianxiety meds, or sleeping med as long as the patient takes them 6 hours apart?
I do not recommend patients with chronic non-malignant pain, especially those on chronic opioid therapy, take benzodiazepines, barbiturates, muscle relaxants, sedative-hypnotics, sleeping medications, and anti-anxiety medications except antidepressants/mood stabilizers/anticonvulsants. I use short-acting/IR opioids very sparingly for true rare or predictable episodes of break through pain.
How do we address driving while on opioids? How do we protect ourselves from lawsuits? Do we tell them absolutely no driving allowed?
Patients who take opioids and drive are considered as impaired . You will need to tell your long-acting opioid patients that they should not drive and then make sure you document the conversation.
How often should you re-assess patients when initiating treatment & when maintaining regimens?
Depends on the patient. You might have to see someone every week or talk on the phone every day if they are complicated and having difficulty with a treatment plan. However, if someone is relatively stable, a monthly appointment may suffice.
Should you flush drugs down the toilet?
The FDA recommends this as one acceptable method.
In primary care we get new patients to our practice because of insurance changes and they want opioid therapy plan from previous primary care provider, before records are available. How do you prescribe to this patient when you want to keep them safe from withdrawal side effects?
You should call the previous provider as soon as possible to perform a medication reconciliation and ask about reasons for the change in provider to see if there are any red flags in the patient’s history that would preclude continuing chronic opioid therapy.
How do you treat "Phantom Pain"?
Phantom pain is neuropathic. It is caused by the remodeling of the neural system after the amputation. The best medications to use are non-opioids such as gabapentin, pregabalin, TCAs, or topical medication such as Lidoderm patches. Opioids are really a second line option after the non-opioids choices.
Is there a place for stimulant laxatives (senna) in management of opioid-induced constipation, since opioids decrease colonic activity?
Yes senna laxatives can help with constipation from opioids. I would consider using the formulation with a stool softener included such as Senna-S so that the patient gets two effects, the stool softener and the laxative.
If your patient violates his/her PPA, how do you handle?
Discuss with the patient and determine whether the patient has the ability to comply with the agreement. If not, why? The answer will determine next steps concerning whether to refer the patient for consultation and whether they can continue on chronic opioid therapy.
If a patient has severe constipation and you need to use an opioid antagonist – should the patient continue with their normal schedule/dosing of their ER opioids? Would they be considered opioid naïve?
Severe constipation needs an aggressive bowel regimen. Daily laxative and stool softeners. There are several different oral and subcutaneous medications for opioids induced constipation so would reserve them for the more extreme cases of constipation. Patients will need to be warned of the expected outcome of laxation within four hours so they can plan appropriately.