Risk factors for serious adverse effects like overdose and
mortality72
- Opioid dose and benzodiazepine co-prescription provide only
limited risk estimation.
- Presence of indicators of overall poor health of the individual
appear to be more important risk determinants72:
- Pain polypharmacy and psychopolypharmacy with medications like
gabapentinoids, antidepressants, muscle relaxants and other sedating
medications
- Psychiatric diseases
- Substance use disorders (SUD), current and past
- Medical comorbidity
- Recent acute health care utilization, especially for SUD
- The higher the number of risk factors, the higher the risk of
overdose and suicide behaviors.
- Past occurrence of adverse effects should be considered as a
risk factor for similar adverse events in the future.
- High Impact LTOT adverse effects to be ascertained include
misuse of opioids or other medications and substances, opioid use
disorder, any overdose or suicide events, any events with compromised
mentation or respiration, psychiatric destabilization, medical
destabilization, hospitalization or sustained medical treatment for
constipation or bowel obstruction, falls with severe injury or
recurrent falls, altered mental status episodes, and other usual
adverse effects.
- Currently, there are no validated risk factors identified for
opioid induced chronic pain syndrome (OICP). It makes intuitive
clinical sense to use the risk factors for overdose and mortality as
risk factors for OICP too.
———————–End
Box
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Risk/benefit analysis to estimate LTOT effectiveness and
further management: Patients on LTOT can be grouped into 3 broad
effectiveness categories based on the risk/benefit balance with clear
management strategies (see Figure 1):
- LTOT is effective (Adaptive LTOT dependence): LTOT is
associated with discernible functional benefits, no high impact
adverse effects (see box 4) have occurred, and the future risk of
adverse effects is low. In this situation, LTOT can be continued as is
but there should still be concrete planning with the patient about
when and how LTOT will stop in the timeframe recommended above.
- LTOT is ineffective (Maladaptive LTOT dependence):
LTOT is associated with no or minimal discernable functional benefits,
high-impact adverse effects (see box 4) have occurred, and/or the
future risk of adverse events is high. In this situation, LTOT must be
modified to make it beneficial and/or safer.
- LTOT effectiveness questionable (Adaptive vs maladaptive
LTOT dependence): LTOT is associated with some benefits and no high
impact adverse events (see box 4) have occurred, but the future risk
level is high. This group captures the set of patients that do not
neatly fit into the above dichotomous LTOT effectiveness categories.
The decision to continue LTOT as is or to modify LTOT regimen should
be based on individual evaluation whether the benefits are sufficient
and future risk levels are acceptable.
In all 3 categories of LTOT effectiveness, the healthiest long-term goal
is a medically stable functional life without LTOT. Risk mitigation and
collaboration between the provider and patient is also essential in 3
categories. LTOT reevaluation process is presented as a graphical flow
chart in figure 1.