Box 3: Basic principles LTOT initiation, reevaluation, and
treatment of LTOT ineffectiveness based on the perspective that LTOT is
a therapeutic induction of physiological opioid dependence.
- In LTOT initiation, the patient and providers together must
carefully evaluate the chances of LTOT induced physiological opioid
dependence being maintained in an adaptive form with improved function
and medical stability and not progressing to a maladaptive form with
LTOT ineffectiveness, using predetermined clinical benchmarks to
monitor it. The benchmarks of improvement in function and medical
stability must be collaboratively defined by the patient and provider
considering the individual characteristics of the patient.
- In LTOT reevaluation, the patient and provider together must
determine if the physiological opioid dependence from LTOT is in an
adaptive form with maintenance of improved function and medical
instability or in a maladaptive form with poor function and/or medical
instability. LTOT continuation and modification decisions should be
made based on such a determination.
- In treatment of LTOT ineffectiveness, i.e., poor function,
medical instability, or unacceptable risks on LTOT, the shared goal of
treatment for providers and patients is to transform a maladaptive
physiological opioid dependence into an adaptive form and perhaps into
a non-dependent state through modification of LTOT regimen while
maintaining good function, medical stability, and low risks.
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