Patient selection for opioid therapy

from :Prescribing drugs of
dependence in general
practice, Part C1 – RACGP

Opioid Use in Pregnancy and Breastfeeding

Pregnancy

• Placental Transfer: Most pain management drugs cross the placenta.
• Critical Periods: Weeks 4–10 (organogenesis) and just before delivery.
• Risks:
  • Respiratory depression in the newborn if taken just before delivery.
  • Withdrawal effects in neonates of dependent mothers.
• Recommendation: Avoid drugs during pregnancy whenever possible.
• Consultation: If constant pain relief is required, consult with a specialist obstetrician or pain physician.
• Opioid Therapy:
  • Avoid initiating opioid therapy in pregnant women whenever possible.
  • Prescription of opioid replacement therapy (ORT) for opioid-related substance misuse is a harm minimisation strategy.
  • For pregnant women already on opioids, taper to the lowest effective dose slowly to avoid withdrawal symptoms and discontinue if possible.
  • Consult appropriate expertise when tapering opioids due to potential risks to the woman and fetus.

Breastfeeding

• Occasional Doses: Considered safe.
• Codeine: Should be avoided.
• Repeated Doses: Use with caution, especially if the infant is premature or under four weeks of age.
• Monitoring: Monitor the infant for sedation and other adverse effects.

Opioid Use in Workers’ Compensation Injuries

Risks

• High-Dose Prescriptions: Patients on workers’ compensation are at risk of being prescribed high-dose opioids due to higher levels of psychological distress, poorer surgical outcomes, and prolonged legal proceedings.
• Psychological Distress: Recognize and refer patients showing signs of distress to appropriate health professionals, such as psychologists, early in the treatment process.

Rehabilitation Focus

• Function Increase: Focus on increasing function and minimizing opioid use through non-pharmacological approaches.
• Activity Resumption: Encourage returning to usual activities as soon as possible, including work, sport, recreation, and home activities.
• Complex Cases: Use a multidisciplinary approach involving specialists and physiotherapists with pain management experience for complex cases.

Prescribing Opioids to Patients Who Drive

Risks

• Sedation and Impairment: Opioids can impair driving due to sedation, diminished reaction times, reflexes, coordination, and reduced peripheral vision.
• Risk Period: Increased risk of accidents during the first weeks of starting opioid therapy or after dose increases.

Guidelines

• Stable Doses: Stable doses of sustained-release opioids generally do not impair driving.
• Assessment: Conduct formal driving assessments if concerned about a patient’s ability to drive, especially with high doses or combined sedative medications.
• Advice: Advise patients starting opioid therapy not to drive until a stable regimen has been maintained for at least two weeks.

Licensing

• Austroads Guidelines: A person with an alcohol or substance use disorder that impairs safe driving is not fit to hold an unconditional licence.
• Conditional Licence: May be granted subject to periodic review if the patient meets specific criteria, such as being in remission and having no cognitive impairments or end-organ effects impacting driving.

Opioid Therapy in Sleep Apnoea or Disordered Breathing

Risks

• Increased Sensitivity: People with obstructive sleep apnoea (OSA) have higher sensitivity to opioid analgesia and decreased pain sensitivity.
• Exacerbation: Opioids may exacerbate OSA symptoms.

Recommendations

• Non-Opioid Alternatives: Prefer non-opioid analgesics and pain management techniques.
• Careful Monitoring: If opioids are necessary for patients with mild sleep-disordered breathing, monitor and titrate doses carefully.
• Avoid in Severe Cases: Avoid prescribing opioids for patients with moderate or severe sleep-disordered breathing to minimize overdose risks.

Opioid Therapy in Patients Aged 65 Years and Over

Challenges

• Physiological Changes: Age-related changes in physiology, increased risk of falls, pharmacodynamics and pharmacokinetics, higher prevalence of comorbidities and concurrent medications.
• Assessment Difficulties: Challenges in assessing pain severity and response to treatment, especially with cognitive impairment.

Management Strategies

• Non-Drug Strategies: Use movement, exercise, physiotherapy, and psychological therapies as alternatives or in combination with medication.
• Risk Assessment: Assess risk for falls and implement interventions to mitigate common risks like constipation.
• Monitoring: Regularly monitor for cognitive impairment and other side effects.

Opioid Precautions

• Dosage: Start with lower doses, titrate slowly, and consider lower starting doses, slower titration, and longer dosing intervals.
• Sensitivity: Older patients are more sensitive to opioids, often requiring reduced doses.
• Individual Differences: Tailor analgesic use to individual patients considering comorbidities and other medications.

Summary

• Opioid Use in Special Populations: Careful consideration is required for pregnant women, breastfeeding mothers, workers’ compensation patients, those who drive, individuals with sleep-disordered breathing, and older adults.
• Specialist Consultation: Seek specialist input when necessary, particularly for high-risk patients or complex cases.
• Non-Pharmacological Approaches: Emphasize non-pharmacological methods and minimize opioid use whenever possible to enhance safety and efficacy.