During the American Academy of Pain Medicine’s (AAPM) 32nd Annual Meeting session, “Essential Tools for Treating the Patient in Pain,” Farshad M. Ahadian, MD, discussed his thoughts on the top 10 strategies for success when managing patients taking chronic opioids. These management strategies are briefly summarized here.
1. Communicate Effectively
According to the Federation of State Medical Boards, patient documentation is key. The risk is low that a physician will be punished by either a state medical board or the Drug Enforcement Administration for treatment of a patient in pain when adequate medical record documentation is available.1
2. Determine Risk
Risk factors are both patient- and drug-specific. There are several clinician-rated or patient reported validated assessment tools that make documentation and communication easier. These include:
– Opioid Risk Tool (ORT)
– Diagnosis, Intractability, Risk & Efficacy Score (DIRE)
– Screener & Opioid Assessment for Patients with Pain (SOAPP-R)
– Current Opioid Misuse Measure (COMM)
– Cut Down; Annoyed; Guilty; Eye Opener (CAGE-AID)
3. Risk-based Treatment Plan
The patient treatment plan should incorporate an opioid treatment agreement (OTA), and consideration of consultation, comanagement with psychiatrist or addictionologist, follow-ups, monitoring, safety measures, and drug formulations .2 For example, the OTA should state the frequency of office visits; once every 3 months is ideal. Essentially, the patient’s treatment plan should be individualized, well documented, and regularly evaluated and modified.
4. Opioid-dose Threshold
An opioid-dose threshold does not indicate an absolute maximum dose. Some states have established maximum opioid doses. The more prudent approach to thresholds is physician self-regulation with every dose increase. Published studies show increasing hazard ratios as the dose of opioids increases.4 For example, there is a ninefold increase in the risk for overdose when titrating from less 20 mg morphine equivalent dose (MED) per day to 100 mg MED per day.4 Physicians should be sure to avoid high-risk practices, such as prescribing high doses; extended duration; and concurrent use with benzodiazepines, sedative hypnotics, and barbiturates.
5. Opioid Exit Strategy
An exit strategy should be established at initiation of therapy and be a part of the OTA. Although there is evidence that opioids can provide significant pain relief in the short term, there is limited evidence for sustained improvement in function over longer periods of time, particularly beyond 3 months.2 Therefore, discontinuation of chronic opioids and tapering may be warranted for some patients. If so, they should be reminded that this does not equate to discontinuing other types of therapy or abandonment.
6. Monitoring Programs
Monitoring programs include urine drug testing (UDT), prescription drug programs, and observation of adverse drug events (eg, sleep apnea, endocrine dysfunction). UDT can detect nonprescribed drugs and confirm adherence to prescribed drugs. When considering adverse events, bear in mind that chronic opioid use is a risk factor for central sleep apnea and ataxic breathing. A good screening tool is not available for central sleep apnea; thus, vigilance and communication is important for these patients.
7. Harm-reduction Strategies
Steps to eliminate nonmedical use of opioids include novel formulations and technologies. Additionally, the overdose reversal drug naloxone can be coadministered for patients at high risk or those on high-dose chronic opioids. As of September 2015, 43 states and Washington DC passed laws for layperson access to naloxone.5
8. Multimodal Therapy
Opioid therapy in chronic noncancer pain is no longer ideal as standalone therapy, nor should it be used as first-line therapy.
9. Dismissing a Patient
Dismissing a patient from a physician’s practice is rarely necessary, but may be warranted with repeated hostile behavior, known drug diversion, noncompliance with addiction treatment, repeated noncompliance with treatment plan, and repeated aberrant drug behaviors.
10. Establish Chronic Opioid Therapy Standard Policies and Procedures
This should be jointly developed by all providers in the group, and policies should apply to the entire practice.
Proactive use of standardized strategies will help chronic pain management. However, it is important to review these steps within context. The struggle is treating the individual versus having population medicine. The job of the individual provider is to help identify those patients who are appropriate and can benefit from opioids, and those who are at highest risk for injury from opioids.
Faculty: Farshad M. Ahadian, MD
1. Rannazzisi JT.The DEA’s balancing act to ensure public health and safety. Clin Pharmacol Ther. 2007;81(6):805-806.
2. AMDG 2015 Interagency Guideline on Prescribing Opioids for Pain. http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf. Accessed February 20, 2016.
3. Chou R, Cruciani RA, Fiellin DA, et al; American Pain Society; Heart Rhythm Society.Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014;15(4):321-337.
4. Dunn KM, Saunders KW, Rutter CM, et al.Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-92.
5. David CS, Carr D. Legal changes to increase access to naloxone for opioid overdose reversal in the United States. Drug Alcohol Depend. 2015;157:112-120.
6. Wasan AD, Wootton J, Jamison RN. Dealing with difficult patients in your practice. Reg Anesth & Pain Med. 2005;30(2):184-192.