Safe and Effective Prescribing of Opioids for Chronic Pain

Update on treatment planning, risk management, and ongoing monitoring for efficacy, safety, and adherence in patients treated with opioids for chronic, noncancer pain.

At the 2013 Pri-Med East Conference and Exhibition, Julia Lindenberg, MD, and Marc Cohen, MD, both of Beth Israel Deaconess Medical Center, Harvard Medical School, began their presentation on safe and effective opioid prescribing, titled “Opiates for Chronic Pain: Decision Making, Risk Management, and Monitoring,” by presenting several graphics that summarized the extent of the problem in the US with prescription opioid abuse, misuse, and diversion.

One image was a line graph showing oxycodone, hydrocodone, morphine, and methadone use all trending up from 1997 to 2006. The next graph they showed depicted the use of drugs of abuse by people age 12 and up; marijuana led this race, but prescription pain relievers were in second place. The presenters also revealed a pie chart showing which drugs were most commonly involved with patients’ first illicit drug use. Marijuana was the most common gateway drug (65.6%), but pain relievers were again in second place (17.0%).

The presenters presented results from several studies that highlighted the widespread but varying prevalence of opioid misuse (defined by the National Institute for Drug Abuse as “taking a medication in a manner other than that prescribed or for a different condition than that for which the medication is prescribed”).

In one study involving 196 opioid-treated patients with chronic, non-cancer pain of at least three months duration who were monitored for opioid misuse (as determined by negative urine drug test for prescribed opioids, positive urine drug test for non-prescribed opioids or other controlled substances, diversion of prescription opioids, and other measures), researchers found that nearly one-third of patients had misused opioids.

In another study involving 500 patients who had been prescribed opioids, conducted at the Pain Management Center of Paducah, researchers reported that opioid abuse was seen in 9% of patients, and illicit drug use was seen in 16% of patients. A study conducted at Brigham and Women’s Hospital using data from 470 chronic pain patients who urine drug screening as part of a pain management program found 45% patients had abnormal drug screen results.

To combat the challenge of opioid misuse and abuse, physicians must be aware of and employ safe opioid prescribing practices. The presenters outlined one example of this, the NARC SAFE step-wise approach for safe prescribing.

Narrow diagnosis

Alternative medications/therapies

Risk Assessment

Choosing your opioid

Set expectations

Agreements

Follow-up and monitoring

Evaluate

Risk assessment is an important part of safe opioid prescribing. According to the presenters, there are several “red flag” risk factors for abuse to look for, including a patient’s personal history of substance abuse and a family history of substance abuse. “Yellow flag” risk factors to look for are heavy smokers, young age (under 45 years), legal problems, psychiatric illness, sexual abuse, and distance traveled to obtain a prescription.

When choosing an opioid, physicians are advised to begin with a weaker, short-acting agent (opioid strength, in order of weakest to strongest, is: codeine, hydrocodone, morphine, oxycodone, hydromorphone). If possible, prescribers should also avoid initiating patients with long-acting/extended-release/sustained-release oxycodone (it is associated with high rates of abuse and it’s high street value increases the risk of diversion). When prescribing opioid/acetaminophen combination medications (hydrocodone/acetaminophen products such as Vicodin, oxycodone/acetaminophen products such as Percocet, and others), physicians should monitor patients’ daily intake of acetaminophen (including through OTC products) to reduce the risk of liver damage.

As prescribers are becoming more aware of the legal and regulatory risks associated prescription opioid treatment for chronic pain, the use of signed “Treatment Agreements” that explicitly outline the conditions under which a patient will be prescribed opioid pain medications, the patient’s responsibilities, and the penalties for noncompliance is becoming a standard of care. These agreements include a written management plan that documents patient/clinician responsibilities and typically require patients to pledge that they will not seek opioid prescriptions from other physicians, will not give or sell their medications to others, and will fill their prescriptions at only one pharmacy.

Effective pain management in primary care requires accurate and ongoing pain assessment using a validated questionnaire, such as the PEG, which assesses average pain intensity, the degree to which a patient’s pain interferes with his or her enjoyment of life, and the extent to which their pain interferes with their activities of daily living.

The presenters also advised primary care physicians to periodically review and monitor chronic pain patients for the “six A’s”‑‑Affect (mood), Adjuncts (nonpharmacologic/nonopioid), Analgesia (pain relief), Activities (activities of daily livings, QOL), Adverse effects, and Aberrant behavior. Other monitoring tools include: urine toxicology screens, prescription monitoring programs, and periodic pill counts.

In the context of pain management with prescription opioids, aberrant behaviors include abnormal drug screens, lost or stolen narcotic prescriptions, early refills, illegal activities (selling medications, forging prescriptions), resistance to changing therapy despite adverse effects from current opioid therapy, refusal to comply with drug screens or office visits, use of multiple physicians and pharmacies for prescriptions, frequent complaints about needing more medication, requesting specific pain medications, and/or unsanctioned patient-initiated dose escalation.