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5 Articles in Volume 3, Issue #2
Balancing Pain Management and Professional Risk
Chronic Opioid Rules
Distraction Techniques for Lumbar Pain
Legal Landscape of Pain Treatment
National Pain Data Bank Minimizes Professional Risk

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.

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.

Physician problems with the DEA regarding opioids almost always arise from lack of documentation matching the prescription. Included in documentation is an explanation of the diagnosis, rationale for the treatment plan and an ongoing, updated treatment plan. Diagnosis needs to be thorough. Low back pain is not a diagnosis. It is a symptom. The diagnosis could be degenerative disk disease, osteoarthritis or spondylosis. Documentation should also include the rationale for giving opioids, such as a completion of a substance abuse screen, psychological exam, failure of other treatments and interference with function. The physician must be prepared to explain why unusually larger doses or frequency changes have been prescribed.

Before a physician prescribes a chronic opioid, the patient must have failed first line treatments. Chronic opioid use is not appropriate until non-opioid options have been tried and found inadequate. These include NSAIDs, Ultram, trigger-point injections, physical therapy, and chiropractic care. Documentation of this failure must be shown.

Rule No. 3

Perform urine drug screens on suspected abusers. Remember that the drug screen should be positive for the prescribed drug and no others. Addicts will commonly use the entire drug early in the month, run out and be negative on the drug screen. Alternately, they will sell the prescribed drug, take another and test positive for those non-prescribed substances.

Rule No. 4

Make appropriate consults; share the responsibility of treatment of the chronic pain syndrome. Appropriate consults may include a pain specialist, orthopedist, neurosurgeon and psychological specialist. Psychological examination by a professional trained in addiction is necessary to determine past or potential for abuse and manipulation. Since most chronic pain patients will eventually develop severe depression and/or anxiety as part of the syndrome, psychological care must be addressed as part of the overall treatment of chronic pain. Psychological care is an important part in any multidisciplinary approach to help the patient accept and cope with the psychological effects of chronic pain.

Rule No. 5

Co-morbid conditions must be identified and treated. The chronic pain syndrome is multifaceted and involves the whole body and the whole person. Pain cannot be controlled unless the co-morbid conditions of fatigue, insomnia, sexual dysfunction, anxiety and depression are also controlled. Not only is it poor medical care to treat a chronic pain patient with opioids as the only treatment — while not addressing the other issues — it is a red flag for a reviewing agency.

Rule No. 6

Monthly visits with accompanying documentation of symptoms and improvement of function is necessary to show continued need for the opioids. Constant re-evaluation for success and monitoring for warning signs of addiction or abuse is an ongoing process. Always write a prescription for opioids contingent on a patient evaluation — do not “call in” opioids! This is a red flag for investigators. Be firm and do not make exceptions — no visit means no medication.

Certain patients will make numerous excuses regarding why they cannot come to an office visit and simultaneously warning that they will go into withdrawal if the physician does not fill the opioid early or in the absence of a visit. The answer to this is that they knew the risks when they signed the contract and the contract demands monthly visits. It is the patient’s choice to not follow the contract and the physician’s responsibility to not reward inappropriate behavior. This is a form of manipulation on the part of the patient. Threatening, manipulation and bargaining are signs of drug addiction. Do not be bullied into breaking your own contract by an uncooperative patient. Just remember to chart the conversation and reference to your contract.

At each monthly visit, update the continued need for the medication and functional status and impairment. Function is more important than the level of pain. For example, last month a patient rated his pain a 9 out of 10 and you prescribed a long-acting opioid. This month he rates his pain a nine but he also states that he has been able to interact with his family and assist with the household duties. An improvement in function has occurred and he receives benefits of improved relationships, a sense of participation and being needed. This is adequate reason to continue the opioid, despite the pain rating of nine. After stabilization, periodically try to decrease the dose (by 25%). Reevaluate! Do not just start oxycontin 20 BID and leave it forever without reevaluation (and documentation of such). This medication has potential for abuse and improper prescribing and inadequate documentation raises a red flag for investigators.

The patient must bring in unused medication at each visit. Hoarding may occur even if seen monthly. If a patient is seen Oct. 10, then Nov. 8, and then Dec. 6, he or she will then have two extra days each month. This equals an extra months supply in a year. Hoarding is not necessarily an indication of bad behavior. Normal patients will “hoard” due to a fear response. However, the doctor must keep track of the total dispensed. If such a patient, over a three month period, admits to having six days extra medication left over, there is no problem. However, if he or she has used the extra and has none left, then there is a problem.

Rule No. 7

A signed contract or opioid agreement should be on file. The contract must easily and completely describe the risks and benefits of opioid use. A contract or agreement also needs to explain in simple, direct terms the consequences of breaking the rules of the contract. It is also important to be firm and enforce the consequences. Tolerating rule-breaking by the patient allows the patient to manipulate the physician. Secondly, all patients should have appropriate care and monitoring with no preferential treatment. If a contract is signed, it should be enforced.

Each patient needs to be monitored closely for risks and benefits and reevaluated at every visit for the continued need of opioid therapy.

You do not have to treat everyone and you will not make everyone happy. Giving a non-compliant patient opioids is a severe medicological risk! Changing the rules is not an option. Set your rules and standards in advance. Patients who do not comply either do not get opioids or do not receive your treatment. A common problem is what to do with the non-compliant patient.

Consequences for non-compliance is key. Either force the patient to follow the plan—or quit seeing the patient. Only give opioids to patients who follow the plan. There is risk to the physician and the patient if the rules are not followed. It is okay to refuse opioids to a non-compliant patient. The opioids may improve functioning in a compliant patient, but the withholding of opioids is not life-threatening. There are other options besides opioids. The non-compliant patient is a drain on the physician and medical staff and lowers their compassion and time for the compliant patients.

The contract should also include the rule that the patient may only use one pharmacy to obtain opioid prescriptions and that the physician will check other pharmacies if abuse or diversion is suspected. The benefit of one pharmacy is that the pharmacy will stock the medication so that it is available when needed. Problems occur when a whole prescription cannot be filled or medication has to be ordered. Also the pharmacy will monitor the patient for you. A relationship between the pharmacist and the physician is beneficial. Also remember that most reports of drug abuse starts with a pharmacist’s suspicion — either of the patient or the physician. The pharmacist is your best ally in preventing controlled substance abuse. Keep in close contact and friendly terms with them — they will warn you of potential problem patients. Note that they are also obligated to warn the DEA of potential problems with physicians.

Rule No. 8

Use long-acting opioids for chronic pain and avoid the short-acting opioids — except for breakthrough pain. Breakthrough pain should not be occurring more than twice daily. If breakthrough treatment is necessary more than twice a day, the maintenance opioid should be increased. Avoid mixing long-acting opioids with other long-acting opioids and, likewise, short-acting opioids with other short acting-opioids.

Rule No. 9

When prescribing long acting opioids, the dose should be determined by the maximum effective dose, not the maximum tolerated dose. Maximum tolerated dose would be infinite because you can gradually work up to any dose. Maximum effective dose is the dose that gives the maximum functionality while recognizing that relief in a chronic pain patient is not a totally pain-free state. Contractual dose escalation to obtain 100% pain relief is a fruitless endeavor.

Rule No. 10

Do not prescribe opioids to drug abusers. Although every person deserves pain treatment, it is against the physician and the drug addict’s best interest. A drug addict has no ability to control him or herself when narcotics are present. The drive for stimulation from the drug is stronger than relief from pain. Other non-narcotic options are available. To screen for drug addiction, ask the four CAGE questions:8
C. Have you ever thought you should
cut down on your drinking or sub-
stance use?
A. Have you ever felt annoyed by
other’s criticism of your drinking
or substance use?
G. Have you ever felt guilty about
your drinking or substance use?
E. Do you have an eye-opener (start
your day with alcohol or other
substances)?

Summary

Each patient needs to be monitored closely for risks and benefits and reevaluated at every visit for the continued need of opioid therapy. Figure 2 is a checklist to use to determine if the opioid is successful or becoming addictive or abused. Opioid prescribing should be one component of a balanced multidisciplinary approach to pain relief and improved functionality. Concurrent treatment options might include physical therapy, chiropractic, injection, as well as other treatments.

Last updated on: May 25, 2017
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