Is it safe to prescribe opioids for pain relief to a patient with a history of diphenhydramine overdose and diagnoses of depression, anxiety, and PTSD?

Safe Opioid Prescribing for a Patient with History of Diphenhydramine Overdose and Psychiatric Conditions

It is safe to prescribe opioids for pain relief to this patient with a history of diphenhydramine overdose, given their current psychiatric stability, successful use of opioids after the overdose, and absence of crisis indicators.

Assessment of Risk Factors

When evaluating the safety of opioid prescribing in this case, several key factors support a favorable risk-benefit profile:

• Patient has been in stable psychiatric condition since the overdose in March 2022
• Patient is engaged in therapy and in psychiatric remission
• Patient has safely used opioids as prescribed following multiple surgeries since the overdose
• Patient shows no current indication of being in crisis
• The overdose involved diphenhydramine, not opioids

Evidence-Based Approach to Prescribing

The CDC Clinical Practice Guideline for Prescribing Opioids (2022) provides a framework for safe opioid prescribing that can be applied to this patient 1:

1. Perform risk assessment: While the patient has depression, anxiety, and PTSD (which can be risk factors), these conditions are currently well-managed, and the patient has demonstrated responsible use of opioids in the past.

2. Monitor for warning signs: Continue to assess for signs of:

   • Anxiety or depression worsening
   • Difficulty controlling opioid use
   • Work or family problems related to medication use
   • Sedation or slurred speech (early warning signs of overdose)

3. Implement safety measures:

   • Prescribe the lowest effective dose
   • Provide short-duration prescriptions with appropriate follow-up
   • Consider prescribing naloxone as a precautionary measure
   • Check the Prescription Drug Monitoring Program (PDMP) with each prescription

Important Considerations

Mental Health Monitoring

The 2016 CDC guideline emphasizes that clinicians should "remain alert to signs of and screen for anxiety, depression, and opioid misuse or opioid use disorder" 1. For this patient:

• Schedule regular follow-up appointments to assess both pain control and mental health status
• Coordinate care with the patient's mental health provider
• Be vigilant for any changes in psychiatric stability

Avoiding Benzodiazepines

The CDC strongly recommends avoiding concurrent prescribing of opioids and benzodiazepines 1:

• Verify the patient is not receiving benzodiazepines for anxiety management
• If the patient is on benzodiazepines, consider alternative treatments for either pain or anxiety

Patient Education

Provide clear education about:

• Safe storage and disposal of medications
• Risks of combining opioids with alcohol or other sedating substances
• Signs of opioid adverse effects and when to seek help
• The importance of taking medications exactly as prescribed

Conclusion

While past psychiatric history and overdose history warrant attention, this patient's current stability, successful prior use of opioids, and engagement in treatment support the safety of opioid prescribing for pain management. The key is maintaining appropriate monitoring, using the lowest effective dose, and ensuring continued psychiatric stability.