Prescribing practitioners should keep in mind that using opioids to treat chronic pain in addicted patients is rarely considered appropriate. Treating acute pain in the addicted patient should involve prescribing only the quantity necessary to address the acute episode, avoiding as-needed dosing, using medication around the clock for an appropriate period of time, closely evaluating the patient’s medication use, increasing recovery-related activities during episodes of pain, and promptly destroying of all unused medications.


Prescribing opioids for chronic non-cancer pain


Data do not support the prescribing of opioids for the safe and effective treatment of CNCP; however, if conservative treatment measures fail and the prescribing of opioids is inevitable, patients with CNCP should be screened very carefully prior to the initiation of therapy.

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Some experts believe that the available risk-screening tools have not been proven valid in the prediction of benefits or harmful adverse events related to the use of opioids in the treatment of CNCP.20 Other experts say such screening tools such as the Screener and Opioid Assessment for Patients with Pain (SOAPP), the Opioid Risk Tool (ORT), and the Diagnosis, Intractability, Risk, Efficacy (DIRE) instrument have acceptable validity.20,21 


Practitioners should consider the presence of the following to be relative contraindications for prescribing opioids to treat CNCP: history of alcohol, tobacco or other substance abuse; active presence of alcohol, tobacco, or other substance abuse; borderline and/or antisocial personality disorders, mood disorders, or psychotic disorders. 


Before initiating chronic opioid therapy (COT), practitioners should document the failure of other modalities and perform a detailed assessment that addresses substance abuse and psychiatric history. Screening tools that assess for the presence of alcohol/drug abuse, depression, and the potential for opioid abuse are valid and helpful.22

A baseline drug screen should be considered as well. COT guidelines should include a written patient-provider agreement that addresses treatment goals and outlines such parameters as that clinician being the single provider of opioids, the patient utilizing a single pharmacy, commitment to follow-up visits, and random urine drug testing.


Once COT has been initiated, the following screening tools may be used to identify opioid misuse: Prescription Drug Use Questionnaire (PDUQ), Current Opioid Misuse Measure (COMM), and Pain Medication Questionnaire (PMQ).21

Clinician guidelines pertaining to COT should also include regular documentation of patient functionality and referral to a chronic-pain-management specialist if a patient gets to the point that high-dose therapy is required (i.e., >120 mg/day morphine equivalent dose or whenever the prescribing practitioner feels uncomfortable managing the patient’s COT).


Adverse effects related to opioids


Before prescribing opioids, practitioners should be aware of the potential adverse effects (AEs) associated with these controlled substances. Prompt identification and treatment of AEs may be necessary to improve patient compliance. 


Constipation is the most common AE pertaining to opioid therapy20 and can be addressed by increasing fluid and fiber intake and with the utilization of stool softeners and laxatives. Other common AEs include nausea and vomiting, which may be treated with oral and rectal antiemetic medications.

Opioids may also lead to myoclonus, pruritus, incoordination, decreased reflexes, somnolence, inability to concentrate, and clouded mentation. Studies have shown the use of extended-release opioids to be related to hypogonadism and decreased testosterone levels, which may lead to sexual dysfunction, decreased libido, and fatigue.20 Significant and potentially fatal AEs include respiratory depression and overdose. 


Ensuring safety when prescribing opioids


Safety can be promoted by educating the patient prior to and during COT. The patient-provider agreement is an ideal start to ensuring safe practices among persons receiving COT. Prescribing practitioners should also consider involving the patient’s family members and caregivers in COT safety education.

Safe practices for patients receiving COT include following a treatment plan that specifies appropriate dosage, storage, duration of therapy, and disposal of opioids. Clinicians should try to avoid prescribing combinations of opioids and benzodiazepines, which can contribute to CNS depression and is a major cause of fatal overdoses.


One of the best ways clinicians can maximize safety when prescribing controlled substances is by accessing their state prescription drug monitoring program (PDMP) for every patient receiving these medications.

The PDMP is an electronic database that has been implemented in most states to assist with the identification of patients who are potentially diverting opioids or engaging in the practice of “doctor shopping,” which is a felony. Table 2 provides an overview of the ways safety can be maximized when prescribing opioids. 


Table 2. Safe practices for prescribing opioids
Use statewide prescription drug monitoring programs (PDMPs).
Conduct a thorough pain assessment that includes a complete history regarding substance abuse or mental illnesses prior to initiating chronic opioid therapy (COT).
Create a patient-provider agreement prior to initiating COT.
Include the patient’s family members and caregivers in opioid utilization and safe-handling education whenever appropriate.
Promptly identify and treat opioid-related adverse effects.
Utilize screening tools and drug screening prior to and during COT.
Promptly identify and treat opioid-related adverse effects.
Utilize screening tools and drug screening prior to and during COT.
Refer to a specialist when the patient’s pain management requires increasing, at-risk levels of opioids.
Play an active role in the development and implementation of policy measures to ensure opioid-related safety.

Conclusion


With the increasing prevalence of opioid abuse and addiction in the United States, it is vital for prescribers to be aware of recommended practices to treat pain appropriately while minimizing the potential for opioid abuse and addiction.

Practitioners can play an instrumental role in reducing the incidence of opioid abuse and addiction by conducting a thorough pain assessment prior to considering use of opioids, following evidence-based prescribing practices, and maximizing safety when prescribing these medications.

Practitioners may also play an influential role in the development of policy measures to promote appropriate opioid prescribing among health-care providers and safer utilization among patients. 


Mary Atkinson Smith, DNP, FNP-BC, is a nurse practitioner at Starkville Orthopedic Clinic in Starkville, Miss., and an adjunct faculty at Capstone College of Nursing, University of Alabama, in Tuscaloosa.

Scott Hambleton, MD, FASAM, is the medical director of the Mississippi Professionals Health Program in Ridgeland, which is the state Physician Health Program.


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References


  1. Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmacol. 2008;16:405-416.
  2. Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend. 2006;81:103-107.

  3. Zacny J, Bigelow G, Compton P, et al. College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: position statement. Drug Alcohol Depend. 2003;69:215-232.

  4. U.S. Food and Drug Administration. FDA announces safety labeling changes and postmarket study requirements for extended-release and long-acting opioid analgesics. Available at www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm367726.htm.

  5. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1492. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm.

  6. Colliver JD, Kroutil LA, Dai L, Gfroerer JC. Misuse of prescription drugs: Data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health (DHHS Publication No. SMA 06-4192, Analytic Series A-28). Rockville, Md.: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2006.
  7. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305:1315-1321. Available at jama.jamanetwork.com/article.aspx?articleid=896182.

  8. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:537-542. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6226a3.htm.

  9. Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Available at www.samhsa.gov/data/NSDUH/2k10ResultsRev/NSDUHresultsRev2010.htm.

  10. National Research Council. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: The National Academies Press, 2011.
  11. Hooten WM, Bruce BK. Beliefs and attitudes about prescribing opioids among healthcare providers seeking continuing medical education. J Opioid Manag. 2011;7:417-424.

  12. Deyo RA, Smith DH, Johnson ES, et al. Opioids for back pain patients: primary care prescribing patterns and use of services. J Am Board Fam Med. 2011;24:717-727. Available at www.jabfm.org/content/24/6/717.long.

  13. Express Scripts. Bad Rx decisions cost poor U.S. states most. Available at lab.express-scripts.com/insights/drug-options/map-bad-rx-decisions-cost-poor-us-states.

  14. Express Scripts. Patterns of narcotic use and abuse. Available at lab.express-scripts.com/prescription-drug-trends/patterns-of-narcotic-use
-and-abuse/.

  15. U.S. Department of Justice. Controlled substance schedules. Available at www.deadiversion.usdoj.gov/schedules/.

  16. Vera RL. Brief reports from the pain management symposium. Opioid 
therapy in chronic pain management. Proc (Bayl Univ Med Cent). 2000;13:
249-250. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC1317050/.

  17. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of four pain intensity rating scales. Pain. 2011;152:2399-2404.

  18. Garra G, Singer AJ, Taira BR, et al. Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients. Acad Emerg Med. 2010;17:50-54.

  19. World Health Organization. Cancer Pain Relief. With a guide to opioid availability. 2nd ed., Geneva: World Health Organization; 1996.

  20. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130. Available at www.guideline.gov/content.aspx?id=16165.

  21. Passik SD, Kirsh KL, Casper D. Addiction-related assessment tools and pain management: instruments for screening, treatment planning, and monitoring compliance. Pain Med. 2008;9:S145–S166.

  22. Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013;309:657-659.



All electronic documents accessed April 14, 2014.


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From the April 01, 2014 Issue of Clinical Advisor