Signup for PPM
Opioid Prescribing and Monitoring
How to Combat Opioid Abuse and Misuse Responsibly

When to Use Opioids: What I Didn't Learn in Medical School

It is almost impossible to look at the news or the medical literature today and not see a story related to the rising rate of opioid prescriptions or the almost epidemic jump in opioid overdose deaths. More than 125 papers have been published on the topic since January 2016 alone.

There are many factors driving this public health crisis, from the increasing prevalence of pain in the general population to the influence of the pharmaceutical industry in popularizing opioids for the treatment of chronic pain to the liberalizing of pain treatment.1 Currently, about 30% of Americans report experiencing some type of acute or chronic pain.2 In 2014 alone, US pharmacies dispensed 245 million prescriptions for opioid medications.2 Accompanying this growth in prescriptions has been a surge in misuse and abuse of the drugs, with opioid overdose now a leading cause of accidental death in the US—second only to motor vehicle crashes.3 Of drug overdose deaths, more than a third (37%) reported in 2013 were attributable to pharmaceutical opioids.2 In addition, substance abuse treatment admissions for opioids other than heroin have increased more than sixfold between 1999 and 2009.4

Despite these troubling statistics, many physicians report that they are not confident in their knowledge of how to prescribe opioids safely, detect abuse or addiction, or initiate a conversation regarding these issues with their patients.2 Nevertheless, the standards for managing pain and medication abuse are becoming tighter and putting both prescribers and patients in jeopardy. This is why, now more than ever, we must improve awareness and education regarding appropriate opioid use.

Very few medical schools currently provide training in pain management, and fewer still provide courses in addiction beyond abuse of illicit substances and alcohol.2 A study looking at emergency physicians in both Georgia and Florida in 2013 revealed that 22% of the participants reported that they had not received any training regarding opioid management and screening for abuse.5

Knowing the pharmacology and metabolism of a drug, unfortunately, does not translate into knowing how to use it appropriately. The Office of National Drug Control Policy recognizes this knowledge gap and is encouraging improved education for both medical students and physicians currently in practice with a Drug Enforcement Agency (DEA) license.5 The general consensus is that teaching and training practices for physicians, nurse practitioners/physician assistants (NP/PAs), nurses, dentists, and pharmacists should be enhanced in the areas of pain management, opioid pharmacology, and abuse or addiction. Such training could be achieved through web-based programs and continuing medical education (CME), and is becoming a part of the requirements for licensure in several states.1-3 But even web-based training would likely offer or require only limited CME hours. So while this might raise awareness amongst clinicians, it certainly will not make them experts. Unfortunately, an overemphasis on abuse and prevention may limit how well and how often prescribers employ opioids.

When and How to Prescribe Opioids

Just as all forms of hyperglycemia do not warrant insulin use, not all pain needs opioid treatment. Some patients will do fine with nonpharmacological techniques, and many others will have contraindications to chronic opioid treatment. It is best to try nonopioid analgesics, alongside behavioral modification, before resorting to opioids.

For the past 20 years, the increased involvement of pharmaceutical manufacturers in medical education and marketing has changed both the perception and prescribing practices of opioids in the US. The real change came in the 1990s when the marketing of opioids for the treatment of moderate to severe, chronic noncancer pain led to a stark increase in prescriptions.1 In 2007, a pharmaceutical company pleaded guilty in US federal court to criminal charges that it misled both doctors and patients in claiming its controlled-release opioid was a safe alternative to other opioids.6

No high-quality studies have evaluated opioid therapy compared to no opioid therapy for long-term (>1 year) outcomes in chronic pain.4 Randomized controlled trials (RCTs) and double-blinded studies would be challenging and perhaps unethical; what patient with moderate to severe pain would agree to being randomized to a placebo arm for longer than 1 year? Many 12-week RCTs and open label extension studies longer than 6 months are available to gauge efficacy and long-term effectiveness.

In the absence of sufficient longer-term evidence, the general consensus is that alternative (nonpharmacologic as well as pharmacologic) therapies should be tried prior to initiating opioid agents for chronic noncancer pain.2,4,7 Nonpharmacologic therapies that have been useful in treating chronic pain include cognitive behavioral therapy (CBT), exercise therapy, yoga, massage, meditation, and acupuncture. These modalities can be combined with pharmacologic therapy, such as nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, and anticonvulsants, as well as interventional therapies, such as epidural injections, biofeedback, and nerve stimulators.2,7

If all of these modalities prove inadequate to control pain, opioid therapy may be added. In the short run, this will likely be more labor intensive for prescribers and may result in more patient dissatisfaction. However, in the long run, clinicians and patients must learn that not all pain requires prescribing controlled substances and, like for many other diseases, lifestyle modifications are at least as, and often more, desirable than medication management.

The majority of prescriptions for opioids today are actually limited to the treatment of acute noncancer pain.1,7 Such use could be minimized as well by looking at both time limits to therapy and the use of other modalities. Most mechanical joint pain, for example, is time limited and does not warrant opioid use.

Before prescribing opioid medications, it is important to know how to screen for opioid misuse and abuse. There are certain factors that place patients at higher risk for abuse, including a history of opioid abuse or major depressive disorder, ongoing psychotropic medication use, reports of higher pain scores, and poorer health status.8 Prior to initiating opioids for chronic pain management, patients should be screened for substance use disorders with tools such as the Opioid Risk Tool (ORT) or the Screener and Opioid Assessment for Patients with Pain (SOAPP). In addition, providers should utilize state prescription drug monitoring programs (PDMP) to identify patients who are “doctor shopping” for pain medications, as well as administer a urine drug screen prior to prescribing and throughout the course of treatment to assess for illicit drug use.2,7

For many years, it was believed that pain would protect against the development of addiction. Numerous studies regarding addiction have since disproved that belief.2 No high-quality studies to date have evaluated the effectiveness of risk mitigation strategies, such as risk screening instruments, urine drug screening, PDMP data, management plans, frequent monitoring intervals, pill counts, or abuse deterrent formulations, on improving outcomes related to addiction, overdose, misuse, or abuse.2,4 Despite this lack of evidence, most providers agree that drug screening tools should be used and that patients should be carefully and regularly monitored.2,7 (For more on assessment and monitoring, see Chapters 4 and 5.]

What to Do After Initiating Opioids

Once the decision is made to start a patient on opioid therapy for chronic pain management, expectations should be set regarding pain control, and a patient-provider agreement (PPA) for long-term opioid therapy should be in effect, outlining what patients need to do in order to be compliant (see Chapter 4). After initiation, patients should be regularly monitored for adequate pain control and signs of addiction, as well as given unscheduled urine drug screens.3 Cardinal signs of addiction include pronounced craving for the drug, obsessive thinking about the drug, and inability to control use of the drug. If these signs are recognized, the prescription for the offending agent should be discontinued, and the patient should be referred to an addiction management service.2

While evidence regarding long-term opioid therapy for chronic pain is limited, as noted, the available literature suggests that risk of harm is directly correlated with both dosing and duration.4 When initiating opioids, the lowest effective dose should be used for the shortest required time, and any increase in dosing should be slowly implemented and carefully monitored.2 This allows tapering and discontinuation of opioids in patients who do not appear to be receiving a benefit or who are engaging in practices that put them at risk for overdose, such as high alcohol consumption, benzodiazepine use, or poor adherence to dosing (see Chapter 6).2,3

When treating acute pain, avoid long-acting or sustained-release formulations. However, with chronic pain management, short-acting opioids should be used first at the lowest possible dose to pinpoint effective dose levels7; at subsequent visits, extended-release opioids are preferred, depending on the amount of opioids required by the patient on an average day and on the temporal nature of the patient’s pain.2,7 While opioids should be titrated both up and down slowly, depending on patient response, studies have shown that there is no single opioid that is truly “safer” than another, although methadone has been shown to be more dangerous due to a variable half-life, difficulty in dose titration, genetic variability, and drug interactions.9 All opioids carry a risk of abuse.2,10

Once a clinician starts a patient on an opioid, he or she should know how to stop the therapy if necessary. Patients should be monitored at least once every 3 months while on therapy to assess compliance, signs of abuse, and ability to step down or step up therapy.7,11 This can be accomplished through ongoing discussions with patients regarding the risks and benefits of the medication, including realistic pain relief goals. Some of the risks associated with long-term opioid use include, but are not limited to, overdose, abuse, addiction, diversion, and accidents (work-related, motor vehicle, etc).4 Tolerance to nausea and vomiting, respiratory depression and sedation, and euphoria can develop within a couple days on opioids. However, tolerance to analgesia in patients who continue on long-term opioid therapy is controversial. Many patients stay on the same dose, with ongoing analgesia, for months or years.12 If a patient reaches a point where he or she is no longer receiving a notable benefit from the opioid medication, it should be tapered slowly to prevent symptoms of withdrawal, with concomitant initiation of both nonpharmacologic and pharmacologic nonopioid therapies for pain management.2

In short, determining who should receive opioids, and how to manage that treatment, is a complex process. Opioids remain useful and powerful medications that should be reserved for appropriate patients. Keeping in mind the risks and benefits and realizing that not all pain needs opioid therapy may lead to better outcomes for our patients.

Last updated on: April 29, 2019
Continue Reading:
Think Combination Therapies
close X