Opioids for the management of chronic non-malignant pain

There has been a dramatic increase in the use of opioid analgesics for the management of chronic non-cancer pain. With the increase in prescribed opioids, there has also been an increase in emergency department visits, prescription drug substance abuse admissions, overdoses and deaths. Over the past 20 years, drug overdose death rates have increased from around 3 per 100,000 to more than 12 per 100,000.

Rates of headache, back pain and neck pain diagnoses increased significantly in Arkansas Medicaid enrollees between 2000-2005. With the increase in diagnoses, there was also found to be an increase in the use of prescription opioids for non-cancer pain.

Research shows that if dosing guidelines are not followed, there is an increased risk of side effects and unintentional overdose. Most physicians who prescribe opioids for chronic pain have not received formal training in chronic pain management.

Strategies for success

Management of patients on opioids

  • Check PDMP every time prescribing a Schedule II or Schedule III opioid and the first time a benzodiazepine is prescribed.
  • Document in the patient record that the PDMP was checked.
  • Consider multimodal therapies such as superficial cold/heat therapy, spinal manipulation, physical therapy, psychotherapy, acupuncture, massage, etc.
  • Get informed consent with discussion of benefits and risks of opioid management in patient record.
  • Get signed pain contract and baseline urine drug screen.
  • Evaluate patient at least once every six months by a physician licensed by the Arkansas State Medical Board.
  • Conduct random urine drug screens and pill counts.
  • Consider prescribing Naloxone when clinically appropriate.
  • Periodically review the schedule drug treatment with the patient and any new information about etiology of the pain and appropriateness of continuing medications.
  • Keep accurate records of medical history, physical examination, evaluations and consultations, treatment plan objective, informed consents, agreements, and medications prescribed.

Know the facts about opioids

  • Use the lowest effective dose. Use caution and reassess before increasing dosage to 50 morphine milligram equivalent (MME) per day. Avoid increasing dosage to ≥90 MME/day.
  • Dose escalation has not been proven to be effective for chronic non-malignant pain.
  • The risk of overdose or death increases with dosage.
  • Opioid dependence can develop in as little as days or weeks with daily use.
  • Patients developing opioid dependence may have difficulty tapering dosages.
  • Other risks associated with Opioid use include tolerance, increased pain sensitivity, respiratory depression, unintentional overdose, and chronic constipation.
  • The risk of respiratory depression increases when opioids are combined with non-opioid medications with sedative side effects.
  • Polypharmacy occurs frequently with elderly and critically ill populations causing an increased risk for adverse drug events.
  • Approximately one half of deaths resulting from prescription pain medication involve the use of at least one other drug.

Improve office systems

  • Using an Electronic Medical Record (EMR) for prescribing may assist in the management of potential drug interactions.
  • Patients receiving chronic opioid therapy benefit from a medical home in which the primary care provider directs care and coordinates consults with other care providers as needed.

Educate patient and family about opioids

  • Inform your doctor about all medications currently taking and do not begin any medications without first consulting your doctor.
  • Do not take more than the prescribed amount.
  • Report side effects to your doctor.
  • Do not share opioid/pain medication with others.
  • Keep opioid/pain medications locked away to keep others safe.
  • Avoid driving and activities that require alertness since drowsiness and dizziness can occur.
  • Avoid drinking alcohol while taking pain medication.
  • Do not throw away or flush unused opioid/pain medications. Take unused medication to drop-off locations sponsored by local police departments.

Web resources

 

Provider resources

ADMG (Agency Director’s Medical Group)

Agency Medical Director’s Group Interagency Guidelines 

Arkansas Department of Health

Arkansas Prescription Monitoring Program

Arkansas Medical Practice Acts and Regulations

Arkansas Medical Practice Act

Arkansas Take Back Program

Search collection sites

Centers for Disease Control

FDA

New Safety Measures Announced for Extended-release and Long-acting Opioids

U.S. Department of Justice

DEA—Office of Diversion Control

 

Articles

CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016
Deborah Dowell, MD, MPH1Tamara M. Haegerich, PhD1Roger Chou, MD1
Author Affiliations Article Information
JAMA. 2016;315(15):1624-1645. doi:10.1001/jama.2016.1464

Reducing the Risks of Relief — The CDC Opioid-Prescribing Guideline
Thomas R. Frieden, M.D., M.P.H., Debra Houry, M.D., M.P.H. April 21, 2016
N Engl J Med 2016; 374:1501-1504 DOI: 10.1056/NEJMp1515917

Additional resources

Arkansas State Medical Board

Arkansas State Board of Pharmacy

PainEDU.org—peer-reviewed materials

Physicians for Responsible Opioid Prescribing

Patient resources

Video

“The Hungry Heart” – a documentary film on prescription drug addiction