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PPM: In today’s climate of public scrutiny surrounding the use of opioids, what do clinicians need to know about opioid prescribing and risk of addiction?
Dr. Passik: If you look at the way the debate has played out in the popular press, you would think the solution to the whole problem is just to stop prescribing opioids. There’s a perception that drugs are the problem and they’re often made out to be the culprit. These are medications like all others, with benefits and risks. I first admonished the pain community about the unbalanced rhetoric in this area in 2001.3 While the rhetoric was unbalanced then, that does not justify it being equally unbalanced in the other direction now. Two wrongs don’t make a right, particularly not when patients will suffer.
It takes three elements to create drug addiction, regardless of whether a person has pain or whether it’s a recreational use scenario to begin with. First, you have to have a drug with rewarding properties. Second, you have to give that drug to a vulnerable person. Third, that person must use that drug at a vulnerable time (Table 1). In pain management, we have exposure to drugs with rewarding properties and all of our patients are going through a vulnerable time. By the time a patient tells their doctor they’ve had pain, they’ve usually had that pain for months, they may be depressed, they may not be working, they might have financial and family stress because of disabilities, etc. What’s really important, then, for primary care physicians is to assess the patient’s personal vulnerabilities to addiction and then individualize treatment based on an assessment of this fairly small set of known vulnerabilities. In other words, which patients are likely to have a hard time using opioids responsibly if you expose them to opioids knowing they’re already stressed?
In terms of risk factors for drug addiction, they can include people with a history of drug abuse; people with a history of active psychiatric problems, particularly those associated with self-medication or impulsivity; young age (under 35 years); family history of drug abuse; and whether they smoke cigarettes, which has been shown to be a risk factor (Table 2). The important thing for physicians is to get the message that the drugs themselves are not the problem, the problem is that we haven’t taught clinicians how to assess this known set of risk factors, and then deliver opioid therapy differently depending on whether or not the person is at high or low risk.
PPM: What sort of due diligence do clinicians need to do regarding opioid prescribing?
Dr. Passik: Many years ago, I wrote a paper about the so-called four As.4 We use this metric as a research tool to study outcomes in therapy, but it’s also a documentation aid. Primary care providers need to know how to assess and document outcomes in these four domains in order to protect themselves and protect the patient. Therefore, every time you see a patient, you should assess for the four domains of outcome, and record them in the charts. Is a person getting analgesia? How is their activity level or function? How are their adverse effects or side effects? What’s going on in their adherence or aberrant behaviors? (Table 3) You need a good outcome in all four domains to justify continued prescribing. If primary care providers document like that; conduct a physical exam for pain; and have some form of monitoring of adherence, including urine drug testing, a pill count, or checking the prescription monitoring program, more often than not you can avoid problems or detect them early and intervene. This will also allow you to make sure the patient isn’t running into problems regarding loss of control of their medicine.
PPM: Is there a fair middle ground? What’s the best way to implement these practices?
Last updated on: March 25, 2013
First published on: January 1, 2013