For an estimated 25 million Americans, chronic pain levels remain significantly high enough to interrupt normal daily life. The annual cost of chronic pain will soon exceed the $600 billion mark due to medical expenses and decreases in work productivity. These staggering costs are higher than medical expenses and lost wage amounts associated with diabetes, cancer, and heart disease combined.
Challenge and Responsibility of Opioid Addiction and Abuse to Clinicians
Clinicians know all too well that managing chronic pain is not an easy task. The proper care for patients using opioid therapy requires carefully considering many diverse factors. While opioids may be effective for treating some patients’ chronic pain, opioid prescriptions present the increased risk for patients misusing or abusing the drugs, resulting dependence or addiction.
Opioid prescription use grew exponentially from 1990 to 2004. It has remained high in the years since, with almost 220 million prescriptions written in 2011 alone, compared with 76 million in 1991. As more prescriptions are written, the number of opioid addictions, overdoses, and deaths have risen. The highest dosage opioid prescriptions have historically been written by providers in pain management, physical medicine and rehabilitation, and anesthesiology.
Opioid prescription, abuse, and addiction are complex issues that are often misunderstood. In many situations, the source of abused opioid medications is not new prescriptions but surplus or leftover prescription medication, often obtained from a relative or friend.
Providers from all areas of medicine must consider their role in addressing the increased use, abuse, and dependence on opioids by individuals suffering from chronic pain. To ensure patient safety, providers should carefully weigh the benefits against the risks to make informed decisions. The ASA has published a resource entitled “Considerations for Long-Term Opioid Use in Chronic, Non-Cancer Pain Conditions,” which recommends strategies designed to reduce opioid abuse.
Thorough Evaluation and Documentation
Providers should begin the patient assessment process with a thorough history and physical exam. The assessment should seek to determine the underlying issue and evaluate how pain affects the patient’s life. Consider effectiveness of any prior approaches for pain management and think through other factors that may impact the choice of therapies. Keep in mind the goal is to develop a treatment plan to help reduce pain and return the patient to a desired quality of life.
Carefully Assess Dependence Risk
It is crucial to factor in each patient’s risk of becoming dependent upon opioids. Patients with higher chances for opioid addictions include those with current or past substance misuse or abuse and those with mental disorders and personal issues such as legal problems, limited social network, martial/relationship problems, and employment/job satisfaction.
Drug Interactions and Other Conditions
During patient evaluation, consider any additional conditions or diseases. This is especially important in the geriatric population, where co-morbidities are more common. It’s crucial that clinicians monitor all factors carefully during the duration of the opioid treatment.
Sedatives such as benzodiazepines can increase risks for side effects when combined with opioids. Any illness that affects the respiratory function, such as pneumonia or COPD, may pose more risks for patients who are taking opioids for pain management. Opioids and benzodiazepines both have been known to worsen cases of obstructive sleep apnea.
Consider Several Treatment Options
Treatment for chronic pain need not be limited to prescription opioids. Alternate treatments include interventional pain treatments, psychological approaches, and/or occupational/physical therapy. There are many effective interventional pain procedures that can help reduce the use of oral opioids for non-cancer, chronic pain.
Standardize Protocols for Opioid Prescribing
Introducing standardized opioid protocols in a clinical practice will provide help for clinicians (along with their staff) when discussing opioid therapy with patients and their families.
Practice-based policies and protocols can set expectations between patients and clinicians at the beginning of treatment. Patients will need to understand both risks and benefits associated with opioid use. Consider implementing parameters to dictate the maximum doses and duration of opioid use.
Proceed with Empathy and Compassion
A clinician’s ability to convey empathy and compassion sets the tone for interacting with the patient. Clinicians need to have an empathetic demeanor when addressing a patient’s report of pain.
Each patients’ response to pain and treatment options will vary based on cultural, psychosocial, and genetic factors. Therefore, it will be necessary to reassess the pain and treatment methodologies periodically.
Communication, Goals, and Plan of Care
It is imperative for clinicians to set realistic expectations with patients regarding the responsible use of opioids, including goals for reducing pain and improving function. The ASA highly recommends documenting a patient treatment agreement from the start. Continue to discuss goals and options throughout treatment to make changes as needed.
Consider Opioid Prescriptions as Trials
The initial prescription of opioids as a treatment for chronic pain should be handled as a trial rather than a long-term therapy solution. This should be transparent to the patient from the start so that if the trial is unsuccessful, the use of opioids will be discontinued.
Create a Plan to Eliminate Use of Opioids
The top priority for any clinician considering prescribing opioid therapy should be patient safety. When the time comes to taper off the use of opioids, clinicians and patients should discuss the plan prior to initiating the therapy. This will outline the best methods to discontinue the medication if the therapy is ineffective.
Reevaluate Opioid Effectiveness
Once opioid treatment has started, there must be a continual assessment of the patient to ensure sufficient progress to justify continuing the use of opioids. The ASA recommends adjusting dosages as needed and performing urine drug testing every 3 months.
Additionally, check Prescription Drug Monitoring Programs, or PDMPs, to help identify other medications that have been prescribed to a patient within a given state.
Consider Prescribing Naloxone with Opioid Therapy
There is growing support for prescribing Naloxone along with opioids for patients with a high risk for overdose. Patients at high risk include anyone prescribed a dose equivalent to 100 mg of morphine or more daily, those who have an underlying respiratory issue, those with a history of substance abuse (non-opioid), and those who have been prescribed another hypnotic or sedative.
When prescribing Naloxone, clinicians should strive to educate patients and caretakers, such as family members or friends, to recognize the signs of an overdose and resuscitation care. Often it is the patient’s family and friends who are called upon to administer Naloxone, and some training may save a life.
Clinicians must have a firm understanding of the indications, risks, and pharmacology for opioids, along with the indications of abuse or aberrant drug-seeking behaviors. Any clinician with the ability to prescribe this medication should continue educating themselves on chronic pain and pharmacology. This will contribute to the safe prescribing of the medications now and in the future.
American Society of Anesthesiologists Publication: “Considerations for Long-Term Opioid Use in Chronic, Non-Cancer Pain Conditions” https://www.asahq.org/resources/resources-from-asa-committees/considerations-for-long-term-opioid-use