18 Feb Pain Management for Patients with Special Considerations
Special considerations must be given to pain management in patients with chronic diseases, sleep disorders, sleep apnea, those who are pregnant, people with chronic kidney disease, and individuals with liver dysfunction. Opioids are commonly prescribed to treat chronic pain. Statistics show that 20% of patients going to the doctor present with noncancer pain symptoms. In 2012, 259 million prescriptions for opioid pain medication were written in the United States.
Opioid prescriptions per capita increased 7.3% from 2007 to 2012, and the prescribing rates increased more for family practice and internal medicine than other specialties. Rates of high opioid prescribing vary across states, but assessment and treatment of chronic pain are challenges of many health providers.
Patients with Sleep-Disordered Breathing and Sleep Apnea
The risk factors for sleep-disordered breathing include obesity and congestive heart failure. Experts note that careful monitoring should be done when these patients are prescribed opioids. In addition, doctors should avoid prescribing narcotics to people with moderate to severe sleep-disordered breathing to minimize the risks for opioid overdose.
Obstructive sleep apnea is the main risk factor for opioid-induced respiratory depression. These sleep disorders and breathing conditions can lead to increased risk related to comorbid disease, such as disruptive drug-seeking behaviors and poorly controlled pain.
Pulmonary and Cardiac Disease
Opioids can lead to respiratory depression in people with known pulmonary or cardiac disease. In addition to obstructive sleep apnea, patients with pulmonary comorbidities are at increased risk for respiratory depression. People with chronic obstructive pulmonary disease (COPD), smokers, and those with restrictive lung disease (asthma and bronchitis) have increased risk when using narcotics due to reduce oxygen reserves and increased carbon dioxide retention.
Comorbid cardiac disease, such as pulmonary edema and poorly controlled congestive heart failure, may increase a person’s risk for opioid-induced respiratory depression. Patients with heart disease should be given alternative medications, as opioids may compromise renal clearance in these people.
Patients with Renal and/or Hepatic Insufficiency
Clinicians should use extreme caution and increased monitoring when prescribing opioids combined with acetaminophen in patients with hepatic insufficiency. This is due to the risk for liver toxicity and poor metabolism. In addition, patients with renal insufficiency should not take nonsteroidal anti-inflammatory drugs (NSAIDs), due to the poor excretion rates.
Several opioids have active metabolites that must be eliminated by the kidneys. Renal failure will increase a patient’s risk for sedation or respiratory depression. Morphine, fentanyl, and hydromorphone are all metabolized in the liver to active metabolites. These could be problematic for people with liver and/or renal compromise. Alternative treatment measures should be used for these patients.
Patients with neurologic conditions or injury to the central nervous system may be more sensitive to the sedating effects of narcotic analgesics. These patients already have cognitive impairment, or mental confusion, and taking opioids could increase the risk for delirium. When treating pain in these patients, doctors must look for alternative forms of treatment.
Women who are pregnant should avoid taking certain medications. Opioid use during pregnancy is a risk for both the mother and developing fetus. Some clinical studies have shown an association between narcotics in pregnancy and stillbirth, preterm delivery, and poor fetal growth. Opioid use/abuse during pregnancy also can lead to neonatal opioid withdrawal syndrome, and clinicians should carefully weigh benefits against the risks before using these drugs for treating chronic pain.
For pregnant women already receiving opioids, the Maryland pain doctor will consider tapering the drugs and changing the patient over to another medication. Opioid use may be treated with buprenorphine or methadone, which is associated with improved maternal outcomes. The doctor must arrange for delivery at a facility that can evaluate for, monitor, and treat neonatal opioid withdrawal syndrome, should a pregnant female start using opioids during pregnancy. In addition, codeine should be avoided for mothers who are breast feeding, or if used, it should be given in the lowest dose possible.
All Star Pain Management offers top tier pain treatment to a broad range of patients with a Board Certified Doctor –
ZVEZDOMIR ZAMFIROV, MD (Dr. Zed). This includes medication management and interventional procedures at multiple locations including Annapolis and Glen Burnie MD. Most insurance is accepted, call us today!