Chronic Opioid Rules
Opioids are potentially dangerous medications that can lead to accidental overdose, death, or impairment around machinery, or while driving an automobile. Therefore—even for the chronic pain patients who generally need opioids to improve functionality—they should be used judiciously and wisely.
Patients may be frustrated by the burden of these rules, not being able to adjust their own medication, or take as much medication as they want. The patients’ idea of an ideal opioid would be one they could take whenever they wish in whatever amount they wish. However, this class of medications is not one that patients can safely be trusted to adjust on their own.
Giving a patient an addictive medication and allowing them free access to timing and dosage is out of the question — there must be physician supervision. No one can self-supervise one’s own addictive medication, even if the patient is not an addict and the medication is clearly indicated. It is critical to set rules and parameters. The patient must follow the plan for the benefit of both the patient and the physician. If the patient fails to comply, then it is a potentially dangerous situation for both. The key to appropriate chronic pain management is to establish rules (or guidelines) for treatment and then tailor the care to each individual. Following these rules lowers the risk of supporting drug diversion in the patient who plays the role of a chronic pain sufferer in order to sell or abuse opioids. More importantly, these rules will provide the chronic pain patient with proper care.
The Federation of State Medical Boards of the United States, Inc. guidelines want physicians to follow a “usual course of professional practice” to find a balance between appropriate patient care and risk of investigation. Their focus is on appropriate treatment and documentation, not on quantity or chronicity of opioid prescriptions.1 Appropriate treatment reduces pain and ensuing pain relief improves function—whereas addiction decreases function.2 Co-morbid conditions must also be treated, treating the whole person and improving overall functioning.2,3 A multidisciplinary approach gives the patient multiple options, of which opioid therapy is only one part.
Chronic pain is one co-morbidity in the Chronic Pain Syndrome. Once pain has become chronic, all parts of a patient functioning are affected. Insomnia, fatigue, sexual dysfunction, depression and anxiety also occur. Each co-morbidity worsens the others and, in turn, lowers functioning.3 Pain can be categorized as nocioceptive or neurogenic. Nocioceptive has a physical origin of pain that is opioid receptive. Neurogenic pain is chronic with often no observable physical origin of pain.4 Neurogenic pain will demonstrate incomplete opioid response or none at all.
Opioids play an important part of the overall pain treatment program — but only a part and never 100%. Proper application of opioids varies from patient to patient — from significant usage in one patient (good response, no tolerance, little co-morbidities) and minimal usage in another (poor response, neurogenic pain, tolerance, addiction, co-morbid diseases). This article discusses the rules for the use of opioids in the patients for whom they are indicated and illustrates signs of success and failure5,6,7,8 (see Figure 1).
Explanation of Checklist Questions
Signs of Opioid Addiction
Signs of Success
Objective, measurable improvement in function without signs of addiction, tolerance or abuse.
Rule No. 1
There should be a single prescribing physician using a multidisciplinary approach to pain management. Dosages must be monitored and re-evaluated with monthly visits and, because there is only one managing physician, the risk of overdose and withdrawal is eliminated.
Rule No. 2
Complete a thorough history and physical. Not only does this mean performing a thorough H&P, but also generating a detailed documentation of it.9 Releases should be signed for any previous providers regarding previous treating doctors and/or substance treatment and/or psychological evaluations. The release must give permission for the physician to talk with other professionals regarding pain and associated co-morbid conditions only. HIPPA regulations forbid blanket releases, so the release must be specific. The contract needs to specify that the physician or his staff will be contacting previous caregivers or pharmacists. Refusal to sign a release prevents the physician from managing the drug properly and should raise a flag for further investigation.