Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use

Abstract

As awareness increases about the side effects of opioids and risks of misuse, opioid use and appropriate weaning of opioid therapies have become topics of significant clinical relevance among pediatric populations. Critically ill hospitalized neonates, children, and adolescents routinely receive opioids for analgesia and sedation as part of their hospitalization, for both acute and chronic illnesses. Opioids are frequently administered to manage pain symptoms, reduce anxiety and agitation, and diminish physiological stress responses. Opioids are also regularly prescribed to youth with chronic pain. These medications may be prescribed during the initial phase of a diagnostic workup, during an emergency room visit; as an inpatient, or on an outpatient basis. Following treatment for underlying pain conditions, it can be challenging to appropriately wean and discontinue opioid therapies. Weaning opioid therapy requires special expertise and care to avoid symptoms of increased pain, withdrawal, and agitation. To address this challenge, there have been enhanced efforts to implement opioid-reduction during pharmacological therapies for pediatric pain management. Effective pain management therapies and their outcomes in pediatrics are outside the scope of this paper. The aims of this paper were to: (1) Review the current practice of opioid-reduction during pharmacological therapies; and (2) highlight concrete opioid weaning strategies and management of opioid withdrawal.

Iatrogenic Withdrawal Syndrome in Critically Ill Neonates: A Review of Mechanisms, Assessment, Management, and Prevention

“…28 Regardless of the medications and technique used for managing IWS it should be accompanied by serial withdrawal assessment to evaluate treatment success. 28,29 When referring to the duration of weaning, the literature is unclear on an exact period of time. Options described by authors include a treatment period proportional to the time the infant has been exposed to analgo-sedation, while others suggest a short-fixed period of time up to 10 days.…”

“…For example, the fentanyl dose (µg/kg/h) should be multiplied by 0.05 to 0.1 to achieve the appropriate methadone dose (mg/kg/daily), which should then be divided into every 6-hour administration. 29,31 A similar conversion can be made for midazolam, by multiplying its dose by 0.5 to 1 to achieve the appropriate daily lorazepam dosage, which should also be divided into every 6-hour administration. 31 Alpha-2 agonists, such as dexmedetomidine, can also be used for analgo-sedation purposes during intensive care.…”

“…16 The benefits of this medication include both intravenous and oral administration and long half-life. 28 29 The recommended transition is from intravenous opioid therapy to oral methadone with dose adjustment to achieve the same analgesic effect. 16 Once the transition is initiated the methadone dose should then be reduced by 10 to 20% each day 29 facilitating a longer taper period to prevent withdrawal symptoms.…”

“…28 29 The recommended transition is from intravenous opioid therapy to oral methadone with dose adjustment to achieve the same analgesic effect. 16 Once the transition is initiated the methadone dose should then be reduced by 10 to 20% each day 29 facilitating a longer taper period to prevent withdrawal symptoms. 28 Protocols using methadone to promote opioid weaning have shown a decrease in IWS occurrence utilizing an adjusted methadone dose (based on previous duration and intensity of opioid exposure) which has been shown to be effective in clinical trials.…”

“…28 Regardless of the medications and technique used for managing IWS it should be accompanied by serial withdrawal assessment to evaluate treatment success. 28 29…”