The American journal of managed care
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Patients with moderate to severe pain often require opioid therapy, and many of these patients have multiple comorbid conditions requiring several medications. Guidelines for opioid use do not properly address their use in patients taking multiple medications, as they focus primarily on patient selection, monitoring the patient for drug abuse, and treatment adherence. Moreover, guidelines discuss very little regarding potential drug-drug interactions (DDIs) with opioids. ⋯ In managed care settings, a medication therapy management program is an excellent way to reduce inappropriate polypharmacy, and should result in cost savings. Clinicians should also consider drug-disease interactions and drug-food interactions that may be unique to individual patients. A proper assessment of these interactions may also provide insight into medications that are inappropriate, ineffective, and/or unnecessary in a particular patient.
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Opioids have long been the mainstay of pain control for patients with cancer; however, their use in patients with chronic, moderate to severe pain has increased greatly in the past decade. The risk of drug-drug interactions (DDIs) is a concern with all medications, but is of particular concern in patients using opioids. Most opioids are metabolized via the cytochrome P450 enzyme system, the same system that metabolizes more than half of all prescription medications. ⋯ DDIs can result in significant morbidity and mortality, primarily through overdosing or undertreatment, and are associated with increased healthcare utilization and costs. Clinicians often underestimate the risk of DDIs in patients using opioids. Comprehensive studies of real-world opioid utilization patterns are needed to determine the quantitative impact of opioid DDIs.
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Elderly patients and residents in long term care facilities requiring pain medication often have multiple pharmacologic and physiologic factors that can impact the choice of analgesic. One particular problem with prescribing opioids to the elderly and long term care residents is that opioid safety and efficacy have not been well studied in these populations, and it may be difficult to predict how these patients will respond to opioid treatment. As people age, numerous physiological changes occur, which may affect opioid pharmacokinetics and the potential for drug-drug interactions (DDIs). ⋯ Many elderly and long term care patients have cognitive deficits that impede communication about their pain, thus making detection of opioid DDIs more difficult. Knowledge of the patient's medical history and current prescriptions can help guide the pain management team in the selection of treatment, help minimize the risk of DDIs, and provide these patients with the pain relief they require. There are several practice management recommendations for opioid therapy in the elderly and long term care residents, with the goal of optimizing analgesia while avoiding adverse events and drug interactions.