IDSA GUIDELINES Bundle (free trial)

➤ Providers should be knowledgeable about common pharmacological interactions and be prepared to identify and manage those drug-drug interactions (S-L). Prescribers should follow patients closely when interactions are likely (S-L). ➤ Persons with a history of a substance use disorder addiction should be carefully evaluated and risk stratified in the same manner as all other PLWH with chronic pain (S-L). Values and preferences: This recommendation places a high value on clinical strategies that neutralize bias and reduce stigma in the care of all PLWH and the possibility of behavior change over time. Remark: A patient's history of addiction or substance use disorder is not an absolute contraindication to receiving controlled substances for the management of chronic pain. A risk-benefit framework that views controlled substances as medications with unique risks to every patient ("a universal precautions approach") should be applied uniformly to help providers make fair and informed clinical decisions about controlled substance prescribing. ➤ Persons with a history of addiction for whom the risks currently outweigh the benefits of a controlled substance prescription should have their chronic pain reasonably managed by other therapies, emotional support, close monitoring and reassessment, and linkages to addiction treatment and mental health services as indicated (S-L). Values and preferences: This recommendation places a high value on access to pain management as a fundamental human right with an underlying principle that every person deserves to have his or her pain reasonably managed by adequately trained health care professionals, and that every medical provider has a duty to listen to and reasonably respond to a patient's report of pain. Methadone ➤ A signed release of information to exchange health information between the prescriber and the opioid treatment program (OTP) is recommended prior to any controlled substance prescribing (S-L). Remark: Ongoing communication with the OTP is essential when there are two controlled substance prescribers. Sharing information about a patient's progress in recovery is an important component of the assessment and periodic monitoring of a pain treatment's risks and benefits, for example, whether to pursue a trial of or to continue or discontinue opioid analgesic therapy. ➤ Initial screening with ECG to identify heart rate corrected QT (QTc) prolongation for all patients on methadone is recommended with interval follow-up with dose changes, especially if the patient is also prescribed other medications that may additively prolong the QTc (e.g., certain psychotropics, fluconazole, macrolides, potassium-lowering agents) (S-L). ➤ The splitting of methadone into 6–8 hour doses is recommended to lengthen the active analgesic effects of methadone with the goal of continuous pain control (S-L).

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