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Chronic Opioid Rules

Prescribing opioids for chronic pain requires set rules, a written plan, periodic re-evaluation, and vigilance to prevent illegal diversion of controlled substances.
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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).

Figure 1. Summary of Rules of Opioid Prescribing

Figure 2.

Explanation of Checklist Questions

Explanation of Checklist Questions

Signs of Opioid Addiction

  1. Element of CAGE8
  2. Violates the plan
  3. Element of CAGE8
  4. Violates the plan
  5. Veracity
  6. Increases the risk to you and increases the potential for overdose, side effects, abuse and addiction
  7. First do no harm — addict
  8. First do no harm — addict
  9. First do no harm — addict
  10. Violates the plan
  11. Using insurance for other physician
  12. Has other physician the patient is not telling about
  13. Has other physician the patient is not telling about
  14. Allowing for some individual variability — it is unlikely that one mu receptor agonist will work great if another does not work at all
  15. Longest acting, so least favorable to addict-no peak or “buzz”
  16. Short-acting, so most favorable to addict
  17. Short-acting, so most favorable to addict
  18. Scientific medicine — Lantus 24h, NPH 12h, Reg 4h
  19. Like to see objective evidence of response to drug
  20. Objectivity — if VAS pain is 2 one day and 8 the next day, then there should be concern that the opioid is not working
  21. Non-objective — cannot measure so cannot follow treatment; usually neurogenic and opioid unrespon- sive or psych association
  22. Compounding problem — need to treat this first — pain may be a consequence of psych and therefore the opioid is only treating the symptom; e.g. MTHA secondary to stress; the approach should be stress treatment, not Lortab. Also, be aware that bipolar condition increases the risk of addiction.10,11
  23. Probable drug addict
  24. No diagnosis, so no treatment
  25. No diagnosis, so no treatment
  26. Opioid does not work, so avoid use
  27. Not particularly opioid responsive — needs more attention to sleep and depression
  28. Attempting to flatter the physician: “He’s bad, I know you are good.” The physician tends to write a script to be the hero. The patient knows this!
  29. Patient trying too hard to impress

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.

Last updated on: January 26, 2012
First published on: March 1, 2003