Prescribing Opioids for Pain Management: Answers to Common Questions in Primary Care

Christopher Kolker, MD

Volume 56 - Issue 4 - April 2016

ABSTRACT: While much has been written about the increased rate of opioid prescribing over the last 15 years, as well as the increased rate of addiction to opioids, chronic pain remains a major health concern in the United States. Clinicians often are caught in the middle, trying to balance proper pain control in their patients with the health risks associated with the opioids they prescribe for that pain. To help answer clinicians’ questions about judicious yet effective opioid prescribing practices, this article details a risk-benefit paradigm for determining which patients are appropriate for narcotic medications, the potential pitfalls of opioid prescribing, interactions between narcotics and other medications and substances, and proper documentation of opioid management in patients’ medical records.

KEYWORDS: Opioids, narcotics, prescribing, addiction, pain management
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Narcotic use and addiction have become one of the major health concerns of the 21st century in the United States.1 This critical problem should cause all health care providers to rethink their prescribing practices, so that they first do no harm to any patients by accidental or intentional overdoses or by inducing addictive behaviors. Nevertheless, the undertreatment of pain also is a major health concern. Pain is one of the leading causes of health care visits in the United States.2

Because of this, clinicians often feel caught in a dilemma: They want to prescribe medications that are effective for pain relief, but they fear harming their patients or facing retribution from authorities or if they do.

This article outlines some of the common pitfalls about opioid prescribing and answers questions that clinicians often have but may be afraid to ask, with the goal of more effective opioid prescribing techniques.

1. To which patients should I prescribe opioids?

This might be the single most important question about prescribing opioids. In the vast majority of cases of opioid overprescribing, the initial assessment is the root of the problem—for example, the patient’s risks were not adequately explored before opioids were prescribed, and as often happens, the benefits of opioids were overstated.

A risk-benefit analysis should be done for every patient on opioid therapy, even if for a relatively short time.3 By stratifying patients into risk categories, it becomes easier to see how much risk is being taken by prescribing opioids to a particular patient. High-risk patients have any of the following characteristics4:

  • Uncontrolled psychiatric disorders
  • A history of addiction, especially recent
  • A history of diversion
  • Age younger than 45 years
  • Poor correlation of either physical examination findings or imaging study results with perceived pain level
  • Overreliance on opioids for pain control
  • Refusal to consider nonopioid options for pain control
  • A history of incarceration
  • A family history of addiction
  • A history of preadolescent sexual abuse
  • The presence of obstructive sleep apnea or obesity

Any of these risk factors put a patient at higher risk, and the benefits of opioids would have to be substantial in order to justify this risk. Keep in mind that the benefits of narcotic therapy tend to wane over time as the body becomes more tolerant to opioids, and that opioids provide only partial pain relief for the majority of patients.5

2. What should I include in the medical record before I prescribe opioids?

Poor documentation is a leading cause of clinical errors as well as of disciplinary action from administrative bodies. By documenting what is being done, why it is being done, the risks and benefits, and other methods being tried, a clinician can mitigate these risks and optimize the benefit to the patient. Medical records should include the following3,5:

  • An accurate, complete, and precise as possible diagnosis. General terms such as lumbago should be avoided. Such generic terms may make the precise mechanism of the pain unknown, making it difficult for a clinician to adequately treat it.
  • An accurate history and physical examination findings, especially those relating to the pain-associated diagnosis, along with a description of any psychiatric conditions and/or addictive tendencies, as well as past attempts at pain management.
  • An evaluation of the risks and benefits of opioid therapy, such that it becomes easy for other clinicians to see the rationale for any prescribed chronic narcotic therapy.
  • Results of imaging studies that are appropriate.
  • Consultation evaluations.
  • Up-to-date urine drug screen results.
  • Old medical records, if appropriate.
  • An evaluation of the patient’s psychiatric history. While this does not necessarily have to be done by a psychiatrist, a patient’s addictive history and psychiatric history need to be explored. If there are questions, psychological or psychiatric evaluation should be performed.
  • A pain contract that includes an intent and consent to treat and that thoroughly lays out the patient’s responsibilities.
  • An evaluation of the state’s prescription monitoring program to further ensure that the patient is not “doctor shopping.”

Many clinicians find it nearly impossible to gather and assess all of this information at a patient’s initial visit. Because of this, some clinicians do not prescribe narcotic therapy at the first visit. While this practice usually is not described in the opioid prescribing guidelines, it serves as an indicator that thorough documentation must occur before prescribing can begin.

3. Am I required to continue another clinician’s opioid therapy?

The short answer is no. 

Whenever a new patient is seen who has received chronic narcotic therapy, even from an established health care provider, an initial evaluation still must done by the new treating clinician. The risk and benefits must be discussed with the patient; past treatments and documentation also must be reviewed. The new clinician then will need to decide whether or not to continue narcotic therapy.

There is some subjectivity to this, and at times, competent and reasonable clinicians can disagree about the appropriateness of narcotic therapy in a given patient. However, each clinician is responsible for his or her own actions and should not feel compelled to simply continue another provider’s treatment plan indefinitely. This is especially true if a rigorous evaluation of the patient has led to a new clinical conclusion.

4. What do I tell patients before beginning opioids?

A number of issues must be discussed frankly with patients. Narcotic therapy should begin as a trial therapy, since not all patients with pain benefit from opioids. Second, the clinical monitoring of narcotic therapy must be discussed frankly with the patient, framed in the context of a safety measure to protect the patient from the potential adverse effects of very powerful medications.

The clinician’s expectations about the patient’s behaviors must be discussed before the first prescription is ever written. Many clinicians do not tolerate a patient’s use of alcohol or marijuana in any amount for fear of an interaction with chronic narcotic therapy. If this is a clinician’s policy, it should be discussed with the patient prior to initiation of narcotic therapy. If, on the other hand, small amounts of alcohol are tolerated, for example, the patient should know this. The key is there should be no surprises for the patient, since the clinician has laid out the rules clearly and comprehensively.

Perhaps an even more important discussion with patients is about their expectations. Chronic narcotic therapy should never comprise the entire regimen for pain control. While most people get some pain relief from narcotics, not everyone does, and even those who do benefit usually have only partial pain relief.6 Experienced clinicians can hope to achieve only an approximately 50% reduction in the amount of pain a patient perceives (eg, from 8 to 4 on a 10-point pain scale). Narcotics can ease pain but cannot be expected to eliminate it.

Therefore, another expectation is that other treatments will be needed in addition to opioids. Physical therapy, alternative medications, acupuncture, and mind-body techniques are just a few of the modalities that can be explored for better pain control.6 

Patients need to understand that they must be treated comprehensively in order to have adequate pain control. Less than optimal outcomes often occur when patients begin to over-rely on their narcotic regimen.

5. At what dosage should I begin an opioid Regimen?

Because of the powerful nature of this medication class, it is best to begin at low dosages and titrate up.7-11 Serious errors in judgment can occur if a clinician tries to guess the appropriate dosage based on the patient’s reported pain. If it is suspected that a higher dosage will be needed for adequate pain control, then more frequent follow-up is indicated so that the dosage can be titrated to a more appropriate level. However, starting at very high dosages simply is not indicated.

6. Is it acceptable to start with methadone?

The use of methadone for pain control has been associated with a higher incidence of adverse effects than opioids.12,13 Because of its unique effects on the body via N-methyl-d-aspartate receptors, methadone has more interactions with other medications than do morphine or oxycodone. Furthermore, methadone has been shown to prolong the QT interval, making it particularly harmful when used with drugs exerting same effect (eg, certain cardiac medications, macrolides). Therefore, the use of methadone should be discouraged in all but the most serious cases and should be prescribed only by clinicians who have a great deal of experience with methadone and are willing to do the extra work necessary to adequately monitor patients on it.12,13

7. Does using narcotics with benzodiazepines increase risk?

Using chronic benzodiazepines along with chronic narcotics increases the risk of accidents, overdoses, and morbidity.14,15 Therefore, the use of both together should be discouraged if not prohibited. Many guidelines recommend that benzodiazepines should not be used with narcotics, while others discourage their combination use (Table 1).3,7-10,16-18 However, since both medication classes have sedation and addiction potential, their use together should not be routine.14,15

narcotics

8. Should I prescribe opioids to patients with fibromyalgia?

This is a controversial topic, and some published guidelines state that patients with fibromyalgia should not receive chronic narcotic therapy.12 Because of the changing presentation of the disease over time for many patients, the relatively young age of many patients with fibromyalgia, and the neurologic and muscular components of the condition, chronic narcotic therapy is associated with more complications and has less efficacy for the treatment of fibromyalgia than for other conditions.

In general, fibromyalgia is best treated as a disease of neurologic and muscular pathology. As such, a comprehensive regimen including physical therapy, stretching, yoga, and judicious use of muscle relaxers, anti-inflammatory drugs, and neuroleptic medications are better long-term treatments for fibromyalgia.19

9. What do I do with urine drug screen results?

A patient’s use of other opioids, including and especially heroin, as revealed on urine drug screen results should not be tolerated. The interaction of 2 different opioids and/or a prescribed opioid with heroin simply is too great a risk for a prescriber to bear. However, make sure that the results are not part of an expected pattern of metabolites of the medication found by gas chromatography.20

Persistently negative urine drug screen results raise the possibility that the patient is diverting medication.12 To be fair, a thorough history should be done in order to ensure that the patient simply is not depleting the opioid supply well before the urine drug screen is performed. However, if that does not seem to be the case, prescribing habits may need to be changed for that patient.

Table 2 outlines some of the published recommendations for performing urine drug screens in patients on narcotic therapy.3,7-10,16-18

urine drug screening

10. Do I need to be concerned about marijuana use in patients on opioids?

The medical literature is fairly quiet on this subject, and there are no overreaching US guidelines in place today. The National Institute on Drug Abuse suggests that marijuana could be a gateway drug,21 and studies have shown that it does have an addiction rate of approximately 9% for any user but a 25% to 50% rate for chronic daily users.22 Marijuana also has sedating effects, which could be problematic with concomitant chronic narcotics. On the other hand, marijuana now is legal for medical conditions in many states and in a few places is legal for recreational use.

Therefore, clinicians have to proceed very carefully with prescribing chronic narcotics to patients who use marijuana. 

Some clinicians have a zero-tolerance policy on the grounds that the interaction between marijuana and narcotics could be dangerous, resulting in an increased risk of overdose, accidents, and other problems. Other clinicians have a more lenient approach, citing the availability and legality of marijuana in some jurisdictions. 

However, the overriding construct for clinicians must be that they are responsible for the narcotics they prescribe, and for the interactions that those narcotics have with other medications, especially when the patient’s use of those other medications is known to the clinician. Therefore, if it appears that any medication or other substance a patient is using, including marijuana, has a possible interaction with a prescribed narcotic, the patient must discontinue that medication or substance, whether its use is legal or not.

11. Is there a maximum dosage of opioids?

In most cases, between 120 and 200 morphine equivalents appears to be a reasonable maximum dose for most patients.9,10 While different sources use different maximum dosages,11 it is clear that at a certain level of daily narcotic use, a patient derives little additional benefit, yet the the risk of adverse effects and overdose increases. If a clinician is prescribing more than this, a thorough reevaluation is needed to determine other possible means of adequate pain control.

12. How do I switch narcotics from one class to another?

While discrepancies exist in the literature, if the decision is made to switch from 1 class of narcotic medication to another (eg, from oxycodone to morphine), a dose reduction of at least 50% should be initiated for the switch.12 This is because patients may have incomplete tolerance or cross-tolerance to the medication, meaning that while they may be fairly resistant to 1 medication, they may not be as resistant to other opioid types. Some sources recommend that going back to beginning dosages of the new medication may be in order.

13. If a patient says he or she is experiencing withdrawal, is the patient forcing me to prescribe?

Especially when a patient has not been established as being under a particular prescriber’s care, it is not mandatory that the patient be prescribed narcotics because that patient says he or she has withdrawal symptoms. As one might guess, this could be used as a tactic to essentially blackmail a clinician into prescribing narcotics.

Adequate therapy must be given to a patient experiencing opioid withdrawal. Clonidine sometimes is used for withdrawal symptoms, and hydroxyzine occasionally is used for the associated agitation. (Benzodiazepines should be avoided.11) However, these medications are not considered highly efficacious for treating withdrawal and often are inadequate for treatment of more severe symptoms. 

Referral to a treatment center for buprenorphine plus naloxone therapy or even methadone therapy may become necessary, and if the patient is medically unstable, emergency department care may be required.23

14. What do I need to document throughout the opioid prescribing process?

Proper documentation is absolutely critical when prescribing chronic narcotic therapy to patients. The medical record must include at least the following information7-9:

  • A visit for each time a prescription is given
  • Urine drug screens, with appropriate comments from the provider about the results
  • State-administered patient monitoring programs must be checked (preferably monthly) and commented on appropriately by the provider at each visit
  • Changes in the risks and benefits of narcotic therapy assessed for each patient
  • Reevaluation of the patient’s pain with each visit, often by rating it on a scale of 1 to 10
  • Reevaluation of adverse effects of the medication at each visit
  • Reevaluation of any psychiatric conditions that the patient may have that could affect chronic narcotic therapy and/or pain perception
  • Addiction potential, and the propensity for it to change as therapy progresses
  • Evaluation of activities of daily living with therapy.

15. How do I handle a patient who says the prescribed opioids are not enough and continually demands more?

Statements of frustration and even emotional outbursts are fairly common in patients with chronic pain. Patients often are frustrated that the medication cannot offer the relief they want, or that tolerance to the medication has limited its effectiveness.

A comprehensive pain management plan must be in place before the first narcotic prescription is ever written. A thorough history and physical examination should have been done to understand the etiology of the pain and what therapies might effectively manage it. Conventional medical procedures and techniques must be thoroughly explored. For instance, epidural injections can temporarily relieve low back pain; in some cases, pain pumps may be considered, and for the right patient, surgical treatment must be explored.3,4,6

For patients whose pain is not relieved with conventional medications, a more holistic and balanced approach sometimes must be applied. For example, the use of atypical medications such as gabapentin, pregabalin, and duloxetine should be explored.24 Acupuncture has been shown to be highly efficacious for many kinds of pain, and physical therapy has shown much promise in treating musculoskeletal pain.24

For a patient whose pain is resistant even to these measures, mind-body techniques can be very helpful.24 Tai chi, yoga, and other stretching modalities can be considered.25 And for some patients, meditative techniques can be very helpful for pain.25

The clinician should emphasize to patients that narcotics are one aspect of a comprehensive pain treatment protocol. Doing so addresses any unrealistic expectations about the ability of narcotics to control pain.

16. Do I discharge patients who are nonadherent, who exhibit addictive tendencies, or who have positive urine drug screen results?

One of the most important aspects helping to guide decisions about whether and when to discharge a patient from care is that the institution has a coherent and consistent policy about the care of problematic patients. Some institutions’ policy is to discharge almost no patients but to refuse to prescribe narcotics when risks outweigh benefits. Other institutions may decide to discharge any patient who is nonadherent. While each approach has its merits, it is important that a consistent policy be in place to guide decisions about discharging patients.

For each patient with aberrant behaviors or positive urine drug screen results, the risk-benefit analysis still must be done. Some behaviors simply may warrant more careful inspection, such as random pill counts. Other behaviors, such as obvious heroin use or alcohol abuse, should immediately stop a prescriber from dispensing narcotics because of the increased potential for overdose.26

Christopher Kolker, MD, is a physician at United Community and Family Services in Jewett City, Connecticut.

REFERENCES:

  1. Calabresi M. Why America can’t kick its painkiller problem. Time. June 4, 2015;185(22):26-33.
  2. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2010 Summary Tables. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf. Accessed March 29, 2016.
  3. Chou R, Fanciullo G, Fine PG, et al; American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
  4. Berland D, Rodgers P. Rational use of opioids for management of chronic nonterminal pain. Am Fam Physician. 2012;86(3):252-258.
  5. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004;112(1-2):65-75.
  6. Marcus DA. Treatment of nonmalignant chronic pain. Am Fam Physician. 2000; 61(5):1331-1338, 1345-1346.
  7. Sundwall DN, Rolfs RT, Johnson E. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain: Summary Version. Salt Lake City, UT: Utah Dept of Health; 2009. http://www.health.utah.gov/prescription/pdf/guidelines/final04.09opioidGuidelines_summary%20WEB.pdf. Accessed March 29, 2016.
  8. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Washington, DC: US Dept of Veterans Affairs and US Dept of Defense; 2010. http://www.va.gov/painmanagement/docs/cpg_opioidtherapy_fulltext.pdf. Accessed March 29, 2016.
  9. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. Olympia, WA: Washington State Agency Medical Directors Group; 2010. http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf. Accessed March 29, 2016.
  10. Kahan M, Wilson, L, Mallis-Gagnon A, Srivastava A; National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians: part 2: special populations. Can Fam Physician. 2011;57(11):1269-1276, e419-e428.
  11. Common Elements in Guidelines for Prescribing Opioids for Chronic Pain. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-a.pdf. Accessed March 29, 2016.
  12. Berland D, Rodgers P. Managing chronic non-terminal pain in adults including prescribing controlled substances. Ann Arbor, MI: University of Michigan; March 2009. https://www.med.umich.edu/1info/FHP/practiceguides/pain/pain.pdf. Accessed March 29, 2016.
  13. Terpening CM, Johnson WM. Methadone as an analgesic: a review of the risks and benefits. W V Med J. 2007;103(1):14-18.
  14. Rooney S, Kelly G, Bamford L, Sloan D, O’Connor JJ. Co-abuse of opiates and benzodiazepines. Ir J Med Sci. 1999;168(1):36-41.
  15. Jones JD, Mogali S, Comer SD. Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012;125(1-2):8-18.
  16. Hegmann KT, Weiss MS, Bowden K, et al. ACOEM practice guidelines: opioids for treatment of acute, subacute, chronic, and postoperative pain. J Occup Environ Med. 2014;56(12):e143-e159.
  17. Paone D, Dowell, Heller D; New York City Department of Health and Mental Hygiene. Preventing misuse of prescription opioid drugs. City Health Inf. 2011;30(4);23-30. http://www.nyc.gov. Accessed March 30, 2016.
  18. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2 - guidance. Pain Physician. 2012;15(3 suppl):S67-S116.
  19. Rooks DS. Fibromyalgia treatment update. Curr Opin Rheumatol. 2007;19(2):111-117.
  20. Heit HA, Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manage. 2004;27(3):260-267.
  21. Is marijuana a gateway drug? National Institute on Drug Abuse. https://www.drugabuse.gov/publications/marijuana/marijuana-gateway-drug. Updated March 2016. Accessed March 29, 2016.
  22. Is marijuana addictive? National Institute on Drug Abuse. https://www.drugabuse.gov/publications/research-reports/marijuana/marijuana-addictive. Updated March 2016. Accessed March 29, 2016.
  23. Institute for Clinical and Economic Review, New England Comparative Effectiveness Public Advisory Council. Management of Patients with Opioid Dependence: A Review of Clinical, Delivery System, and Policy Options. Boston, MA: Institute for Clinical and Economic Review; July 2014. http://icer-review.org/wp-content/uploads/2014/04/CEPAC-Opioid-Dependence-Final-Report-For-Posting-July-211.pdf. Accessed March 30, 2016.
  24. Wolsko PM, Eiseberg DM, Davis RB, Phillips RS. Use of mind-body medical therapies. J Gen Intern Med. 2004;19(1):43-50.
  25. Peng PWH. Tai chi and chronic pain. Reg Anesth Pain Med. 2012;37(4):372-382.
  26. Cone EJ, Fant RV, Rohay JM, et al. Oxycodone involvement in drug abuse deaths: II: evidence for toxic multiple drug-drug interactions. J Anal Toxicol. 2004;28(7):616-624.