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13 Articles in Volume 18, Issue #6
Authorities’ Use of Big Data May Harm—or Help—Your Chances of Investigation
Gaps in the Pharmacist’s Pain Management Role
How can cyproheptadine manage complicated chronic pain cases?
Letters to the Editor: Trackable Pills; Buprenorphine; CRPS Diagnosis
Managing a New High-Dose Opioid Patient
Managing Opioid Use Disorder
Medication Selection for Comorbid Pain Management (Part 2)
Mobile Trackers and Digital Therapeutics
New Insights in Understanding Chronic, Central Pain
Nocebo Effects: How to Prevent them in Patients
Polarizing Topics in Chronic Pain
The Fight to End Peripheral Neuropathy
Urine Drug Monitoring

Managing a New High-Dose Opioid Patient

How do I take over management of a patient whose previous clinician prescribed high-dose opioids? Our resident APP responds.
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As an adult nurse practitioner with more than 15 years of experience in pain medicine, I have seen many changes and much growth in the specialty. I’ve witnessed the pendulum swing from the under-prescribing of opioids for pain (at a time when opioids seemed to be the most effective medication), to the indiscriminate over-prescribing of opioids, and now back to a fear of prescribing opioids for any reason and the resulting under-treatment of pain. Fortunately, I have also been part of the paradigm shift from the biomedical model to the acceptance of the biopsychosocial model of pain management and the broader appreciation of interdisciplinary care.

As my Advanced Practice Provider (APP) peers—inclusive of nurse practitioners, physician assistants, and clinical nurse specialists—well understand, our role is to function as autonomous clinicians within a collaborative network of healthcare providers, meeting the needs of patients with acute and chronic pain. This role is expected to increase given the ongoing changes in healthcare, and our aim is to bring a skill set and scope of practice that complements the skills of physicians so that we can help to better manage time constraints and increasing costs together. In addition, we hope to fill the gap left by reluctant healthcare providers ill-equipped to embrace the complexities of providing care for patients with chronic pain.

Over the course of my career, many colleagues have asked about pain management, and by far, the most frequent question is, “How do I take over management of a patient whose previous clinician prescribed high-dose opioids?” In this new column, “For the APP,” I will address additional questions facing the physician assistant and nursing community. Below are some strategies regarding the first question.

Initial Questions and Assessment

Before making a drastic change to the patient’s treatment plan, there are a few upfront questions you must ask:

  1. Is the patient tolerating the opioid dosing? For example, is the patient experiencing dose-limiting side effects, obtaining efficacy, and maintaining activities of daily living, including employment and maintaining social relationships?
  2. Is the patient satisfied with the current treatment plan, including using medications as prescribed and abiding by the treatment agreement?
  3. Is the patient incorporating multimodal treatment approaches, such as non-opioid analgesics, behavioral management strategies, complementary therapies, exercise, or leisure activities?
  4. Does the patient have other comorbid medical conditions, such as poor sleep, depression, anxiety, or obesity?

If the answer to the questions above is “yes,” then, you must assess your comfort, knowledge and tolerance for prescribing high-dose opioids (50 MME/day to ≥ 90 MME/day) and establish acceptable boundaries with your patient, versus referring the patient to another prescriber or practice.

If the patient answers “no” to any of the above questions, then you have a place to start in terms of finding a more effective or more tolerable treatment plan for the patient.

Consider Integrative Referrals

Start by explaining to your patient that the new evidence in effective chronic pain management incorporates treating all aspects of the person (ie, physical, emotional, psychological) and that this approach includes teaching the patient how to best care for themselves so they may be less reliant on medical providers. At this stage, you could also introduce a few self-help guides (eg, books, websites, support groups) and task your patient to become a partner in their treatment outcomes and wellness.

For example, if your patient is only using opioids to manage pain, consider adding an anticonvulsant, antidepressant, and/or anti-inflammatory co-analgesic pharmaceutical. The addition of other pharmaceuticals that the patient does not consider to be “pain medication” will take some education on your part for better patient compliance. If the patient has only been exposed to medical management to treat their pain, then refer for a physical therapy consultation to assess safe mobility and for education on exercises that will help him gain confidence with abilities.

If you find that your patient is reliant on the use of opioids despite harmful side effects (eg, sedation does not allow them to perform daily activities or work, unmanageable constipation, urinary retention, endocrine abnormalities, hyperalgesia), then you should introduce an alternative treatment plan that includes specific, achievable goal setting. To most effectively do this, you may need to refer to a mental health provider to help educate and help the patient explore the emotional and mental ties that they may have to their medication, despite the fact that it may be causing harm. Such an assessment may also help determine whether there is an existing opioid use disorder, which requires another route of treatment. Your obligation is to provide the patient with the best, safest care possible.

Consult the Guidelines

When making difficult decisions about the use of opioids in pain management, you may be able to rely on a few helpful guidelines. For starters, the Centers for Disease Control and Prevention’s guideline for Prescribing Opioids for Chronic Pain1 provides a framework for prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The recommendations address: when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use. The guideline also speaks to the importance of medical management inclusive of non-opioid formulations and to the integration of multimodal care.

Another helpful background document is the FDA’s Assessment of Abuse Potential of Drugs Guidance for Industry.2 This guidance includes recommendations for the development and use of opioids with abuse-deterrent technology, which work to deter certain types of opioid abuse (eg, tampering the product to snort or inject). Abuse-deterrent formulations are not the holy grail of opioid use safety, but they do offer a piece of a much broader strategy to safely prescribe opioids.

Last updated on: December 3, 2018
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