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By P. Hogar. Henry Cogswell College.

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In all cases purchase bactrim 480mg, the physician must balance the possibility of addiction against the benefits of the therapy – striving always to reduce the risk of the former 480mg bactrim with amex. In some cases, however, treatment by an addiction medicine specialist may be indicated. While respiratory depression can occur with patients taking opioids, this risk can generally be minimized if certain precautions are followed. For instance, concomitant use of other neuro-depressive drugs, such as benzodiazepines and alcohol, should be viewed with great caution, since the combination of these drugs has been shown to increase the risk of serious adverse events. In addition, caution with dosing and titrations is indicated for patients with underlying diagnoses such as sleep apnea or end-stage respiratory disease due to the increased risk of cardio-respiratory events. Finally, patients do not develop complete tolerance to the respiratory depressant effects of opioids and the risk of respiratory depression increases as dose increases, regardless of how long one is on opioids. Tolerance: It was previously thought that the development of analgesic tolerance limited the ability to use opioids effectively on a long-term basis for pain management. Tolerance, or decreasing pain relief with the same dosage over time, has not proven to be a significant impediment to long-term opioid use. Experience with treating cancer pain has shown that what initially appears to be tolerance is usually progression of the disease. In the noncancer patient, the failure to respond to increasing doses of opioids should be evaluated very carefully. The possibilities include tolerance, disease progression, non-opioid responsive pain syndromes, and opioid-induced hyperalgesia. Diversion: Diversion of controlled substances should be a concern of every health professional. Attention to patterns of prescription requests and the prescribing of opioids as part of an ongoing relationship between a patient and a healthcare provider can decrease the risk of diversion. Urine and/or blood drug screening, frequent follow up and patient contact, and pill counts are some commonly used clinical interventions that may be helpful in ruling out the issue of diversion. Periodic review of state prescription monitoring program databases, where available, is also a useful tool to monitor compliance and adequacy of communication. Opioids Should Be Prescribed Only After A Thorough Evaluation Of The Patient, Consideration Of Alternatives, Development Of A Treatment Plan Tailored To The Needs Of The Patient And Minimization of Adverse Effects, And On-Going Monitoring And Documentation. Evaluation of the patient: Evaluation should initially include a pain history and assessment of the impact of pain on the patient, a directed physical examination, a review of previous diagnostic studies, a review of previous treatments, a drug history, and an assessment of coexisting diseases or conditions. Treatment plan: Treatment planning should be tailored to both the individual and the presenting problem. Consideration should be given to different treatment modalities, such as an 3 © 2013 American Academy of Pain Medicine - Approved February 2013 interventional approach, a formal pain rehabilitation program, the use of physical medicine and psychological and behavioral strategies, or the use of medications, depending upon the physical and psychosocial impairment related to the pain. Opioids should be prescribed only if the physician reasonably concludes that other treatment modalities will be inadequate to address the patient’s pain. A trial of opioids implies setting expectations that the medications will be prescribed for a short period of time. Continued use will be contingent upon demonstrated improvement in analgesia, physical function and quality of life – and absence of significant adverse events and maladaptive behaviors. Consultation as needed: Consultation with a Pain Medicine or other specialist may be warranted, depending on the expertise of the practitioner and the complexity of the presenting problem. The management of pain in patients with a history of addiction or a comorbid psychiatric disorder requires special consideration. Periodic review of treatment efficacy: Review of treatment efficacy should occur frequently to assess the functional status of the patient, continued analgesia, adverse effects, quality of life, and indications of medication misuse. Monitoring of compliance is a critical aspect of chronic opioid prescribing, using such tools as random urine drug screening, pill counts, and where available, review of prescription monitoring data base reports. Close follow-up and reexamination is warranted to assess the nature of the pain complaint and to ensure that opioid therapy is still indicated. Attention should be given to the possibility of a decrease in global function or quality of life as a result of opioid use. Documentation: Documentation is essential for supporting the evaluation, the reason for opioid prescribing, the overall pain management treatment plan, any consultations received, and periodic review of the status of the patient. Keywords Abstract diagnosis; drug allergy; drug Skin tests are of paramount importance for the evaluation of drug hypersensitiv- hypersensitivity; intradermal test; skin test. Drug skin tests are often not carried out because of lack of concise Correspondence information on specific test concentrations. Knut Brockow, Department of based on history alone, which is an unreliable indicator of true hypersensitiv- Dermatology and Allergology Biederstein, ity. To promote and standardize reproducible skin testing with safe and nonirri- Technische Universitat Munchen,€ € tant drug concentrations in the clinical practice, the European Network and Biedersteiner Str.