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. In Arkansas, 3.2 million opioid prescriptions were filled in 2018, totaling more than 186 million pills. Though this is a reduction from the approximately 235 million pills distributed in 2016, Arkansas is still one of the leading states in the nation for opioid prescribing.

According to the Centers for Disease Control and Prevention, in 2018 Arkansas’ rate of 93.5 prescriptions per 100 people is still above the national average of 51.4. 

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

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 pioid use include tolerance, increased pain sensitivity, respiratory depression, unintentional overdose, and chronic constipation.
  • The risk of respiratory depression increases when opioids are combined with benzodiazepines and other 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.

Management of patients on opioids

  • Check the Prescription Drug Monitoring Program (PDMP) every time prescribing a Schedule II or Schedule III opioid and the first time a benzodiazepine is prescribed. Checking the PDMP is mandated by law (see Act 820 of 2017).
  • 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 co-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.

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.

What you should teach your patients 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.
  • Check to see if your local pharmacy has a drop-off box.
  • Participate in Drug Take Back Day and encourage your friends and family to participate as well.

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

Don’t Run Call 911

Search collection sites

Centers for Disease Control

FDA

UAMS AR-IMPACT https://arimpact.uams.edu/

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

NIH – National Institute on Drug Abuse

Sample pain agreement

U.S. Department of Justice

DEA—Office of Diversion Control

Opioid Prescribing for Chronic Nonmalignant Pain Physician resources:

 

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

CDC Warns of Misapplication of Its Opioid Guideline: Family Physician Expert Offers Insight on Misinterpretations                                                Crawford, Chris, 2019  https://www.aafp.org/news/health-of-the-public/20190509cdcopioidgdln.html

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 Department of Health

Arkansas State Medical Board

Arkansas State Board of Nursing

Arkansas State Board of Pharmacy

PainEDU.org—peer-reviewed materials

Physicians for Responsible Opioid Prescribing