Robert Mallin, MD, Family Medicine and Psychiatry and Behavioral Science, Medical University of South Carolina
Precepting residents faced with patients needing or wanting narcotic analgesics to manage pain can be challenging. Unless there is a policy already in place for the practice, the complexity of such a decision is often overwhelming for the resident. I find they tend to fall into one of two categories: those who always say no to chronic opioid therapy and those who always say yes. As with most difficult management questions, the appropriate answer is somewhere in between. A careful evaluation of the risks versus benefits is key to the decision on how to proceed. I find that if I can give the resident some guidance in the appropriate selection and management of these patients that they are more likely to respond with a thoughtful evaluation of the patient's need. Residents are appropriately concerned about the possibility of substance abuse in these situations, and failure to identify and appropriately address these issues can have a deleterious effect on both the patient and the residents’ license. The American Pain Society has published guidelines that can be useful in proceeding with such an evaluation.1
(1) Before initiating a trial of opioid therapy for for chronic non-cancer pain (CNCP), a thorough history and physical examination including a substance abuse assessment should be undertaken. I remind residents that they should have appropriate diagnostic testing done prior to initiating therapy and that this testing should support a diagnosis that gives a reasonable explanation for the patient’s pain.
(2) The evidence suggests that patients are most likely to benefit from opioid therapy when they have moderate to severe pain that is negatively impacting their lives and have failed non-opioid therapies. Disorders that predict a poor response to opioid pain management include somatiform disorder, chronic low back pain without etiology, daily headache, and fibromyalgia.
(3) Patients that have a personal or family history of substance use disorders are at greatest risk for aberrant drug use behaviors while on chronic opioid therapy. Younger age and psychiatric comorbidity also predict aberrant drug-related behaviors. Preexisting constipation, nausea, pulmonary disease, and cognitive impairment probably predict risk for opioid-related adverse effects. A referral to an addiction medicine specialist or a psychiatrist may be useful in dealing with these patients.
(4) Screening tools such as the Screener and Opioid Assessment for Patients With Pain (SOAPP) and the Diagnosis Intractability and Risk Efficacy (DIRE) are useful tools in evaluating the appropriateness of opioid therapy. Use of these tools will make the decision clearer and easier for the resident.
(5) All patients should be given informed consent and a written management plan that outlines goals, expectations, and potential risks.
(6) Monitoring should include documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies. Typically, random drug screening is performed on all patients to determine compliance with the treatment plan as well as to detect substance abuse. Drug screens should be interpreted with caution. There are often good explanations for positive screens, and by itself a positive drug screen is not equal to a diagnosis of substance abuse.
Clear policies in the practice can also be useful in helping residents to set boundaries and feel comfortable in the use of controlled substances. No after hours prescribing of controlled substances, no controlled substances on first visit, and no early refills without a visit are examples of such policies.
Ultimately I find that I am encouraging those that always say no to consider when opioid therapy is indicated and appropriate and encouraging those that always say yes to consider the risk that they are incurring for their patient and their license. It is gratifying to see residents move closer to the middle of the road when making decisions about chronic pain management.
1. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. J Pain 2009;10(2):113-30.