G.  Adjust Medications As Necessary And Monitor Medical Condition

 

OBJECTIVE

 

Assure appropriate symptom management and safety monitoring for medically indicated opioid or sedative-hypnotic prescription.

 

ANNOTATION

 

1.    Consider prescribing a higher medication dose for adequate symptom relief of tolerant, non-addicted patients.

2.    Set reasonable behavioral and dosing limits and increase monitoring when pharmacologically treating pain or anxiety in patients with a history of substance dependence.

·   Prescribe medication on a fixed schedule, rather than as needed (PRN).

·   Use long-acting medication (such as sustained-release morphine or diazepam), rather than short acting medication (such as oxycodone/acetamenophen or alprazolam).

·   Limit prescription medication to what is needed until the next appointment.

·   Follow the patient weekly or biweekly, at least at the beginning of therapy.

·   Write out the prescription as you would a check, to prevent alteration.

3.    Consider using written contracts for patients receiving opioids or sedative-hypnotics long term, and monitor their conditions carefully, with relatively frequent visits, urine drug screens, and use of collateral informants.

4.    Discontinue prescription (with detoxification, if necessary) and refer to a SUD specialist, if abuse of opioid or sedative-hypnotic medications occurs.

 

EVIDENCE TABLE

 

	Recommendations	Sources of Evidence	QE		R
1	Consider prescribing a higher opioid dose for adequate pain relief of physiologically tolerant, non-addicted patients.	Portenoy, 1994 Portenoy et al., 1997	III		B
2	Set reasonable behavioral and dosing limits and increase monitoring when pharmacologically treating pain or anxiety in patients with substance dependence.	Portenoy, 1994 Portenoy et al., 1997 Scimeca et al., 2000 Longo et al., 2000	III		A

QE = Quality of Evidence; R = Recommendation (See Introduction)