Opioid Renewal Clinic for Improving Care and Reducing Overuse Literature Review Chapter

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Opioid Renewal for Reducing Oversuse and Improving Care

Opioid Renewal Clinic for Reducing Overuse and Improving Care

The chapter carries out a comprehensive literature review on safety and improvement healthcare outcomes for long-term use of opioid therapy for individual. The study evaluates the literatures that relate to the opioids for the management of pain. The chapter also carries out the literature review based on the Cochrane review criteria, and a comprehensive literature search is carried out from Cochrane library, EMBASE, PubMed, and FDA (Food and Drug Administration) database. The paper also uses the systematic reviews, clinical trials and cross references of systematic reviews for the literature review. The hypothesis is developed to test the safety and improvement healthcare outcomes for long-term opioid therapy.


This section develops hypothesis to test improvement strategy that focusing on improve safety and improve health care outcomes on a long-term opioid therapy.

H1: Clinicians are required to scrutinize carefully for evidence of past substance abuse, which will assist in identifying patient's risks of addition or misuse. Physicians should also avoid prescribing Opioid dosages greater than 100mg of MED.

H0: Clinicians are not required to scrutinize carefully for evidence of past substance abuse, which will assist in identifying patient's risks of addition or misuse. Physicians should also avoid prescribing Opioid dosages greater than 100mg of MED.

H2: Patient education is very critical for a long-term use of opioid therapy to educate patients about adherence to therapy, remove fear of opioid therapy and enhance pain management.

H2: Patient education is not very critical for a long-term use of opioid therapy to educate patients about adherence to therapy, remove fear of opioid therapy and enhance pain management.

Long-term Opioid Therapy to Improve safety and Healthcare Outcomes

Pain is an unpleasant emotional and sensory experience caused by potential or actual tissue damage. By consequence, pain can be influenced by psychological, physical, cultural, social, hereditary factors, and pain that persists beyond 3 months is widely viewed as chronic pain.

"Chronic pain is complex and the patient suffering from chronic pain frequently experiences concomitant medical and psychiatric disorders, including mood and anxiety disorders.." (Cheatle,. & Baker, 2014 p 301).

In the United States, pain is the most common factor that leads patients seeking for medical attention. A chronic pain incurs a significant costs on people in the United States and globally, and the costs are estimated reaching $150 billion yearly in the U.S.A. And $235 billion per year in Europe. Based on the enormous costs associated to pain management, the use Opioid continues to increase in the United States and Canada.

A systematic review of the literature conducted by the Agency for Health Research and Quality (2013) shows that "there has been a dramatic increase over the past 10 to 20 years in the prescription of opioid medications for chronic pain, despite limited evidence showing long-term beneficial effects." (p1). Moreover, the accumulated evidence reveals many side effects that can lead to Opioids prescriptions include addiction, abuse, accidental overdose, and diversion. Based on current evidence of long-term effect for the use of Opioid therapy treatment, Burgess et al.(2014) suggest that there is a need to reduce the prescription of Opioid medication at ?100 mg of MED daily because the prescription of more than 100 mg of MED daily leads to a 1.7% annual overdose risk.

Physicians intending to prescribe long-term Opioids for patients should follow their state prescription guidelines to prevent patients receiving Opioids from multiple pharmacies or prescribers. Moreover, clinicians are required to scrutinize carefully for evidence of past substance abuse, which will assist in identifying patient's risks of addition or misuse. In essence, identification of history of addition should necessitate a close monitoring. More importantly, physicians should avoid prescribing Opioid dosages greater than 100mg of MED since high dosage can lead to diversion overdose and abuse.

Franklin, (2014) suggests a patient with no history of substance addiction or abuse can achieve a long-term pain relief if the proper management of Opioids is implemented. In essence, the selected patients can enjoy a long-term pain relief from the use of Opioids. Franklin,(2014) further indicate that healthcare practitioners should use publicly available tools to screen an evidence of current and past substance abuse, significant depression and alcohol abuse using urine test before prescribing Opioids to patients. The strategy will assist physicians to calculate appropriate dosages for patient, which will enhance a long-term use of Opioids without side effects. For example, a recent landmark legislation passed by Washington legislature creates a new rule for Opioids prescription. The rules include dosing criteria, and guideline to track clinical process. The Washington statute provides an evidence-based practice aimed to reduce a potential harm that could be attributed from the use of Opioid therapy for CNCP (chronic non-cancer pain).

Cheung, Qiu, Choi, et al. (2014) recommends different strategies for long-term use of COT (chronic opioid therapy). The first strategy is risk stratification and patient selection. Cheung, et al. (2014) suggests that before physicians initiate a chronic opioid therapy for patients there is a need to carry out appropriate testing that include substance misuse, abuse or addiction. Moreover, physicians should perform a benefit-to-harm evaluation using an appropriate diagnostic testing, and physical examination. The tests should be documented before Opioid prescription for chronic opioid therapy.

Monitoring is another Opioid therapeutic options suggested by the authors, which involves reassessing "patients on COT periodically and as warranted by changing circumstances." (Cheung, et al. 2014 p 403). A clinician should include documentation relating to pain intensity, body physiology level, progress towards therapeutic goals, adherence to the prescribed therapies and presence of adverse events. Moreover, it is critical for a clinician to take urine sample of patients who are not at high risks periodically for drug screen or obtaining other information that can assist in confirming adherence to chronic opioid therapy COT plan of care.

In the case of high risk patients such as patients with history of drug abuse, or serious drug related behaviors, clinicians should only prescribe Opioids for this type category of patients if they will be able to implement more stringent and frequent monitoring parameter. Additionally, clinicians should consider a consultation with an addition and mental health specialists. During the course of treatment, clinicians should constantly evaluate patients' drug related behaviors to assist in making a decision whether to restructure or discontinue with opioid therapy.

However, some patients on COT may require high dose of opioids. With reference to this category of patients, clinicians should reassess opioids adverse effects as well as change in patient's health status. Clinicians should use the option of opioids rotation if patients can experience an intolerable adverse effect with dose increase or enjoy inadequate benefits from dose increase. It is also important for clinicians to educate patients about adverse effects, risks, potential benefits and complications related to opioid misuse. A clinician may consider asking patients to sign a treatment agreement if they are suspected demonstrating higher risks of opioid misuse.

Cheung, et al. (2014) suggests that clinicians should treat specific population differently to improve healthcare and improve safety "outcomes for individual on a long-term opioid therapy." (p 406). Opioid therapy for an elderly patient can be effective and safe if appropriate precautions are implemented, which include more frequent monitoring, longer dosing interval, slower titration, lower starting doses, and tapering of benzodiazepines. On the other hand, clinicians should implement appropriate caution when implementing the opioids therapy for adolescents. By consequence, opioids can present health hazards for adolescents. Thus, it is critical to implement a well defined neuropathic or somatic pain conditions for adolescent patients when close monitoring is available, possible risk of upload misuse is low and effective consultation is integrated in the treatment plan. On the other hand, clinicians should prescribe the lowest possible dose for pregnant women taking opioid for a long period, and therapy can be discontinued if possible.

However, U.S. Department of Veterans Affairs (2013) provides a comprehensive report on the management of a long-term use Opioid Therapy. The report provides guideline for clinicians when initiating a long-term opioid therapy for patients. The report suggests appropriate step to follow in the case of contraindication to a long-term use of opioids. For example, clinicians should avoid initiating a long-term opioid therapy for patients experiencing severe respiratory instability. Moreover, patients demonstrating uncontrolled suicide risk or acute psychiatric instability should not be subjected to a long-term opioid therapy.

U.S. Department of Veterans Affairs (2013) also supports patient's education as one of the important strategy that can be employed in enhancing a safe and improve healthcare outcome for a long-term opioid therapy. Given the deeply prevalence misinformation regarding the use of opioids, there is a need to carry out a repeated education for patients because some patients harbor fear of using opioid therapy by believing that opioid can do more harm than benefits. These unwarranted beliefs can retard pain alleviation or increase dysfunction of pain. Thus, patients and family should be informed about adherence to therapy, and pain management. In essence, patients' education regarding opioid therapy… [END OF PREVIEW]

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