As previously published in WorkCompWire.
Opioid analgesics are commonly prescribed to treat the pain associated with workers’ compensation and auto no-fault injuries. These medications have an important role in pain management treatment and therapy and may be effective for certain indications, including acute pain not relieved by non-opioid analgesics, pain associated with various types of fractures, and some post-surgical pain. Opioid analgesics may also be useful in treating chronic pain when there is evidence of improved pain control, improved level of function or an approved return to work. As with all medications, however, opioid analgesics carry risks, alongside their benefits, and their use may be associated with numerous and potentially serious side effects.
To decrease the incidence of adverse events associated with the use of opioid analgesics, one of the primary goals of therapy should be to manage pain using the lowest effective dose for the shortest duration of time as possible. Another goal should also be to look at non-pharmacologic treatments. If opioid analgesic therapy is determined the most appropriate treatment choice for the claimant, careful management of opioid-induced side effects is essential. Two aspects of that management to consider are medication therapy modifications and side effect control.
Medication therapy modifications are often required to mitigate opioid-induced side effects and typically involve modifying the claimant’s medication therapy depending on the type of side effect the claimant is experiencing. Some of the more common therapy modifications are detailed below.
- Modifying the dosage involves either reducing the opioid analgesic dose. For example, decreasing the dose of oxycodone from 30mg per day to 15mg per day may be effective in alleviating opioid-induced sleep disturbances.
- Altering the route of administration is accomplished by changing from one dosage form to another. An example is moving from an oral product (tablet or capsule) to a transdermal (patch) one. This approach is also helpful if a claimant is unable to swallow tablets or capsules, therefore, switching to a transdermal (patch) product may be more effective.
- Changing the dosing interval, for example moving from taking a medication every eight hours to every twelve, is yet another option than may be useful in alleviating opioid-induced side effects.
- Rotating opioid analgesic medications may be considered when there is a need to help improve pain control or reduce unwanted side effects. This may be accomplished through a trial use of an alternate product. For example, switching from oxycodone to morphine. This approach might be recommended when a prescriber is trying to manage opioid-induced hyperalgesia (OIH), an abnormally heightened or increased sensitivity to pain, or when trying to distinguish the presence of OIH versus medication tolerance.
- Taking an opioid holiday is accomplished through weaning the claimant off of the opioid analgesic for a period to alleviate their side effects and help determine if OIH is present, or if non-pharmacological treatment will relieve the claimant’s pain.
- Removing opioid analgesics from the therapy plan altogether following a claimant-specific weaning plan is also an option. Instead of opioid analgesics, adjuvant medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) as well as certain anticonvulsants and antidepressants may be prescribed to more adequately treat certain types of chronic pain.
Side effect controls may be useful in minimizing side effects in the event that discontinuing opioid analgesics is not feasible. These strategies exist to help address and mitigate the impact of medication on the body without altering the opioid analgesic therapy.
- Adding pharmacologic therapies that are managed appropriately can be safe and effective. However, there are additional risks that must be considered alongside those benefits. Adding a laxative medication to the claimant’s opioid regimen may be beneficial in managing opioid-induced constipation, a very common side effect, but also needs to be monitored for adherence.
- Incorporating non-pharmacologic treatments into the therapy regimen vary depending on the opioid-induced side effect; however, proper diet, exercise and good sleep hygiene are commonly recommended. Keeping a pain journal to document the claimant’s response to the therapy is also useful, not only for tracking success but facilitating discussions with the prescriber.
Achieving better outcomes
Regardless of the route pursued, when taking steps to mitigate opioid-induced side effects, it is always important to consider the claimant as a whole. This includes the presence of comorbid conditions, whether associated and compensable under the claim or not. Similarly, ruling out other causes that may be contributing to the claimant’s symptoms is another important consideration. This is often accomplished by ensuring there is a comprehensive review of medications being prescribed, as well as by using resources such as medication reviews and other clinical tools available from your pharmacy benefit manager to better understand, and holistically manage, the claim.
For more information, read our new white paper, Examining and mitigating opioid-induced side effects.