Question:
“With all the attention the opioid crisis is receiving, will my doctor understand my confusion and fear about possibly being given pain medication?”
Answer:
Awareness of the opioid crisis is not confined to the lay community. Physicians have also been developing an increased appreciation of how powerful these types of medications can be. Although undeniably effective in managing pain, it is clear that many providers and consumers have underestimated the potential difficulties opioid use poses. The Centers for Disease Control and Prevention has published a Guideline for physicians to begin the process of education and awareness in the medical community about how these drugs might be most efficiently used in pain management.1
Presented here in abbreviated form, the Guideline advises:
1. Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.
2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks.
3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.
4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
5. When opioids are started, clinicians should prescribe the lowest effective dosage.
6. When opioids are used for acute [i.e., short-term—KD] pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently.
8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose are present.
9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
With this Guideline in place and ongoing physician education such as that proposed in legislation by Congresswoman Lori Trahan (D-MA)2 and others, it can be possible to stem the tide of this crisis while, at the same time, providing humane and effective pain management.
1https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
2https://trahan.house.gov/news/documentsingle.aspx?DocumentID=1293&fbclid=IwAR0r2m3s-kr3KDHVHMG4wz-SUgvrETaloe5ZOFLz6liuFJZfSqt-85nON1U
Dr. Kent Dean is Director of Clinical Development at CADA (the Council on Alcoholism & Drug Abuse of NWLA) and Director of CADA’s School of Addiction and Behavioral Health. Kent has been a counselor, teacher, and administrator for over forty years. He has been on faculties of Louisiana State University in Baton Rouge, Southern University in New Orleans, and University of Louisiana at Monroe; and he has presented at local, state, and national conferences.