Ask the Expert: Escalating Opioids
Question: How do you manage a patient who self-escalates his or her opioid use?
Answer: First, marshal the facts: Is the dose increase recurrent, or is this a one-time event? Did this happen at the beginning of the patient’s treatment, or was the patient on a stable dose for a while and is now self-escalating? Patients may escalate their opioid dose for several reasons, and the physician’s job is first to find out why and then decide what to do about it. These days, chronic pain patients usually are asked early on to sign an opioid treatment agreement that specifies the conditions for their continued use of opioids. One of the usual requirements is that they do not make changes in their dosage without prior discussion with their doctor. If they do, then one possible explanation is loss of control of their medication use, and loss of control is a key characteristic of addiction. This is more likely if they have a pattern of repeated unauthorized medication changes and other aberrant drug-related behaviors such as repeated claims that the medication was lost or stolen, getting it from more than one doctor, and so on. If the behavior is recurrent and the physician concludes that it represents addiction or drug abuse, then the patient needs referral to an addiction medicine specialist and may no longer be a candidate for opioid treatment. At this point, the physician may decide to wean the patient off the opioid.
Another possibility, however, is that the patient may be getting an inadequate dose of an opioid analgesic and, out of desperation, increases the dose. The physician should talk with the patient about the extent of pain relief he or she is getting from the prescribed dose. (This is actually something that should be done [and documented!] on every follow-up visit.) If this is an early visit, the patient may not yet have reached a level of adequate analgesia. Also, it is very possible that early on the patient obtained sufficient relief due to increased activity (a very desirable outcome!) and, thus, experienced additional pain and needed to increase the opioid dose. A reasonable approach is titrating the dose upward with the expectation that a stable dose will be found that will provide adequate analgesia. It is expected that during the first few visits, an increase in the patient’s dose may be necessary. However, if after months or years of stability, the patient self-escalates because the pain recently increased, the physician should consider the possibility of disease progression. This requires renewed evaluation of the pain, possible referral to an appropriate specialist, and additional treatment modalities, as well as an increased medication dose. And no matter when the self-escalation occurred, the patient should be reminded of the agreement he or she signed and that self-escalation constitutes breaking the agreement. Giving the patient another chance may be a reasonable option on a one-time basis. Of course, if the patient seems unable to stick with the prescribed dose no matter how much it is increased, then see the previous paragraph.
—Jennifer Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management
Answer: Dr. Schneider outlined very eloquently what many would agree is the optimal method of dealing with patients who self-escalate their opioid analgesics. Frequent emergency room visits or obtaining medications from other sources out of desperation are similar situations. As she pointed out, a situation of this importance warrants an investigation into the causative factors, which may include not only a change in the disease, but also behavioral issues. Ideally, if the patient is desperate for control of severe pain, the physician should be notified to explore causation and to titrate analgesics if indicated. A single isolated event should still be counseled, with a review and resigning of the opioid treatment agreement. Early in the treatment course, “dose finding” may require more rapid escalation of the chosen opioid. Good communication between the patient and physician is of paramount importance for this process. Such dialogue is the patient’s responsibility, once he or she agrees on the treatment plan, by signing the opioid agreement.
The physician also has responsibility to the opioid agreement. By not enforcing the “contract” for patient infractions, fault could be assigned to the physician for essentially breaking the agreement as well. In an overdose fatality, the physician may be assigned responsibility, with potential malpractice charges. By not fulfilling his or her responsibility to the agreement, the physician also may be reinforcing maladaptive behavior. If there are no consequences, other than obtaining approval for higher doses of the opioid, there is a high probability that the patient will repeat the infraction. Desperate calls for early refills may warrant having the patient “make do” with his or her residual medication until he or she can be seen for re-evaluation. Repeated offenses can represent addiction or drug abuse, warranting “firing” the patient, or transitioning to a nonopioid regimen with tapering of the opioids. In either situation, a referral to an addictionist is in order. The patient may simply choose to not continue therapy if opioid prescriptions are not assured. Tapering often is carried out with a systematic decrease in opioid tablets over time. Another consideration would be to use a blinded “pain cocktail” in which a compounding pharmacy would prepare an individualized mixture including the opioid that would surreptitiously taper and be discontinued over time.
As Dr. Schneider stressed, the first occurrence warrants thorough re-evaluation of the patient to characterize features of the pain. The patient should be counseled as well. If we are too rigid in our stance, and simply “fire” the patient, nothing may be gained by our attempts at therapy. Giving these patients another chance is a reasonable option on a one-time basis so that we don’t “throw the baby out with the bath water” and lose an opportunity to make gains on their pain.
—Edwin D. Dunteman, MD, MS
St. Louis, Missouri