Opioids for the management of chronic non-malignant pain
Drug overdose continues to plague the United States. The leading cause of injury-related death in the United States is overdose. The Centers for Disease Control and Prevention (CDC) National Center for Health Statistics June 2023 report detailed that in the previous 12 months, over 105,000 people lost their lives due to drug overdose. Opioids are involved in most overdose deaths. Fentanyl, cocaine, and methamphetamine-related overdose deaths have significantly increased. Additionally, the COVID-19 pandemic exacerbated overdose deaths.
The overdose epidemic can impact all of society regardless of age, sex, location, or socioeconomic status, and most everyone in the US has been affected. For every person that dies of an overdose, there are many others who experience a nonfatal overdose, both resulting in emotional turmoil and economic hardship. Additionally, any person who has experienced one or more overdoses is likely to experience another.
Data from the Arkansas Drug Prescription Monitoring Program 2021 report shows Arkansas' opioid prescription drug rate was 75.3 prescriptions per 100 persons. Although declining, Arkansas' opioid prescription rate remains well above the national average. In 2022, the CDC introduced new clinical practice guidelines for prescribing opioids for pain. Research shows that if dosing guidelines are not followed, there is an increased risk of side effects and unintentional overdose. Arkansas physicians can find opioid prescribing guidelines by reviewing the Arkansas Medical Practices Act Statutes and Rules.
Strategies for success
Know the facts about opioids.
- 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 opioid 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 when prescribing a Schedule II or Schedule III opioid and the first time a benzodiazepine is prescribed.
- 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, and massage
- Get informed consent with a discussion of the benefits and risks of opioid management in patient records.
- Get a signed pain contract and baseline urine drug screen.
- Evaluate the 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 scheduled drug treatment with the patient and any new information about the etiology of the pain and the appropriateness of continuing medications.
- Keep accurate records of medical history, physical examination, evaluations and consultations, treatment plan objectives, informed consents, agreements, and medications prescribed.
- Advise where and how to safely dispose of all unused, unwanted, or expired medications.
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 you are 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.
Opioid Prescribing for Chronic Nonmalignant Pain Physician resources
- Check PDMP every time prescribing a Schedule II or Schedule III opioid and the first time a benzodiazepine is prescribed. arkansas.pmpaware.net/login
- Get informed consent with discussion of benefits and risks of opioid therapy noted in patient record. www.ihs.gov/sites/painmanagement/themes/responsive2017/display_objects/documents/SampleConsentControlSub.pdf
- Advise where and how to safely dispose of all unused, unwanted or expired medications www.artakeback.org/
- Arkansas Medical Society https://www.arkmed.org/resources/prescription-drug-education/
- UAMS AR-IMPACT
Revised June 2023