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12 Articles in Volume 13, Issue #1
A Modest Proposal (Thanks to Jonathan Swift—1667-1745)
Chronic Pain: Study of Complementary and Alternative Treatments
Decompression Surgery to Reduce Diabetic Peripheral Neuropathy
Extracorporeal Shock Wave Therapy—Application for Trigger Points
Improving a Practice Model for Prescribing Opioids
Interpretations and Actions Following Cytochrome P450 Testing
Is It Safe to Restart an NSAID Following an Endoscopically Confirmed NSAID-Induced GI Bleed?
January/February 2013 Pain Research Updates
Massage Therapy in an Ambulatory Pain Clinic
Practical Tips in the Treatment of Osteoarthritis of the Hip
Quantum Theory Underpins Electromagnetic Therapies for Pain Management
When a Pain Patient Insists on Alternative Treatments Alone

Improving a Practice Model for Prescribing Opioids

Steven D. Passik, PhD, Interview of Opioid PrescribingSafe prescribing of opioids continues to be a popular topic of debate among clinicians and pain management specialists. There have been several recent controversies regarding opioid prescribing. The concern surrounding opioid over prescribing, for example, recently led a group of physicians (Physicians for Responsible Opioid Prescribing) to submit a petition to the FDA calling for amended opioid drug labeling stemming from safety and efficacy concerns.1 In that same vein, a national conversation also recently began examining whether the benefits of opioids were touted by physicians without properly discussing the risks.2

Practical Pain Management recently sat down with Steven D. Passik, PhD, a leading pain and addiction expert, to discuss how clinicians can better equip their practices to properly identify pain patients best suited for opioid therapy. Dr. Passik recently left academia to become director of addiction research and education at Millennium Laboratories, and principal investigator for Millennium Research Institute, in San Diego, California.


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?

Table 1. Combined Components Needed for Drug AddictionTable 2.  Potential Risk Factors for Drug Addiction

Table 3.  Four Outcome Domains to Document Before Prescribing Opioids:  The Four As

Dr. Passik: Start with the patients you’re likely to have success with. In the early days, proponents of pain management, including myself, probably made it seem like the most egregious error any doctor could make would be to deprive anybody of access to opioids. What we’ve learned over the last two decades is that certain practices only have the resources to treat subsets of the chronic pain population with opioids. For example, we know that primary care professionals are under tremendous time pressure. If you know that you have 8 minutes to see a patient once per month, limited staffing, and limited ability to refer people, you may not be able to prescribe opioids to everybody, but rather you need to be able to treat a patient who can respond to opioids in the setting of minimal monitoring, and also handle a month’s worth of medicine with minimal bells and whistles in terms of the other services. There is a subset of patients with chronic pain who will respond to that. The problem is in our society, probably more than half of people who get opioids get it in that model. In actuality, roughly only 10% or 15% of those patients are probably good candidates for opioids with this low level of monitoring.

Primary care physicians should recognize and respect these limits. They should build a network with providers so they have a psychologist to refer to, they have a physical therapist that will respond to their patients, etc. They should act like the hub of the wheel. In the beginning, though, I would say pick out the patients you know that if you see them infrequently, monitor them minimally, and are able to trust them with a month’s worth of medicine, that’s a good place to start.

PPM: What advice do you have for a clinician who is nervous or hesitant about prescribing opioids?

Dr. Passik: If there’s one thing to do first, it is to stop the practice of giving everybody a month’s worth of opioids at a time. Individualize the prescribing—that’s the first step. Also, you need to assess for the patients who will respond to a month’s worth of opioids and handle it responsibly to begin with—if you do this, you won’t have as many problems. Once you get comfortable with risk assessment, then you can add triage, urine drug testing, and the like as you need it. The first step, though, is to break the habit of treating everybody the same way.

Last updated on: March 25, 2013
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