There is an epidemic of substance abuse, overdoses and deaths related to opioids. This epidemic started in the early 2000s and has escalated. The FDA has addressed this with a Risk Evaluation and Mitigation Strategy (REMS) program. There are challenges in this area and prescribing opioids requires careful considerations. The following are not guidelines; they are merely suggestions or tips for clinicians to consider when they are prescribing these medications:
1) Make Sure the Clinical Diagnosis is Correct Is the opioid you’re giving indicated for the diagnosis that you are treating? When pain is out of proportion to the disease, you need to consider if there is another process or even a malignancy causing the severe pain. A thorough history and physical is helpful in sorting through what is going on. Make sure the opioids are necessary and if they are not working ask “what else is going on?”
2) Consider Alternate Treatments If the pain is from neuropathy or shingles, consider some of the many other neurologic medicines that work for these illnesses. If treating fibromyalgia, remember that there are no controlled studies that suggest opioids help with this condition. Again, consider alternative (often neurologic) drugs. Finally, if the patient was a 7 out of a 10 before starting opioids and is still at the same level after a month, then consider a different treatment regimen.
3) Check Your State's Prescription Drug Monitoring Program (PDMP) The PDMP is your friend. It’s easy to use and you should consider checking the PDMP with every new chronic opioid script. It can help you sort out questions such as:
- Is the patient telling the truth about where he or she received medications?
- Is the patient getting different prescriptions and filling at different pharmacies?
- Is the patient currently using other controlled substances? We suggest transparency when you are checking the PDMP. Tell the patient how it works and why it is valuable.
4) Perform an Addiction Screen There are many screens available. The CAGE screen is simple and well known. Some of the others, such as the Screener and Opioid Assessment for Patients in Pain (SOAPP), are made especially for chronic narcotic use and are subtler. It is important to know if the patient has a high-risk for addiction and/or if there is an underlying psychological disorder or prior abuse that makes opioids have a higher addiction potential. These types of screens can provide information that is important to know prior to prescribing chronic, potentially addictive drugs.
5) Do a Urine Toxicology Screen In conjunction with the above, a urine toxicology screen should be considered before embarking on treatment. It can help answer several questions:
- Is the patient using other street drugs?
- Is the patient claiming that he or she is not taking opioids, yet testing positive on the toxicology?
- Is the patient supposedly on drugs, yet the toxicology screen is negative? Consider diversion in this situation. Check with your lab to see what drugs show up on their screen for the patient. Not every urine toxicology screen checks for the same drugs and has the same sensitivities. You can make random urine toxicology screens a condition of your continued prescribing via the opioid contract/agreement, but must still inform the patient that you are doing the test (it cannot be done surreptitiously).
6) Have the Patient Sign a Pain Consent Form The MagMutual Patient Safety Insitute has an informed consent form for opioids on our website.. The informed consent form is a tool to help you review the risks and benefits for using opioids as well as the potential side effects (constipation, sexual dysfunction, and drowsiness are among the many potential side effects). Remember to warn patients about using opioids while driving or using heavy machinery. And make sure you talk about the interaction with other drugs, especially alcohol and marijuana.
7) Also Consider a Pain Agreement This is distinct from the informed consent form. It is similar to that discussion you had with your teenager when you gave him or her car keys for the first time. The agreement establishes the boundaries, rules and regulations that you’ve set up around the prescribing of opioids. An example rule would be “no refills on the weekend or at night.” These established rules also help you deal with stories you may hear such as “the cat ate the Oxycodone,” “my script got stolen,” or “I lost my pills down the toilet.” A sample pain agreement is available on the MagMutual Patient Safety Institute’s website.
8) Understand the Street Price Law enforcement has given us the range of the street price for Oxycodone as $1 to $2 per 1mg. This means that a one-month script of 120 Oxycodone (5mg) could be sold for as much as $1,200. Once you see the prices that Oxycodone, Percocet and Oxycontin can be sold for, you will understand why diversion is such an issue.
9) The Buzz Words Addiction is the compulsive use of a drug that results in personal harm. Often in these cases, there is psychological dependence and a history of preexisting abuse. Tolerance refers to decreased effectiveness over time. The important issue is to avoid labeling patients as “addicted” when they are really becoming tolerant and needing to increase their medication. Finally, there is physical dependence, which is the abstinence syndrome that occurs when discontinuing opioids. Withdrawal symptoms following discontinuation of opioids does NOT indicate that the patient is an addict; most patients can suffer some withdrawal symptoms following a course of continuous opioids even when indicated and appropriately administered.
10) Listen Some of our most difficult patient conversations occur around these drugs. It can be a complex issue. The patient wants pain relief and we have an obligation to relieve suffering. On the other hand, there are times when it is clear that opioids are not what are best for the patient. “Primum Non Nocere” is the first precept of medical ethics. Instead of starting the boundaries discussion with a resounding NO, listen to what the patient is concerned about, understand his or her fears, and see if there is compromise that will meet the patient’s needs and still be considered safe medicine.
Created by MagMutual from materials provided by COPIC as part of MagMutual and COPIC’s alliance to improve patient safety and quality of care for all of our PolicyOwners.