Are opioids right for your patient?
Some patients respond better to opioids than others, says Jennifer Schneider, MD, PhD, an internist with Arizona Community Physicians and medical director of Kachina Center for Addiction Recovery in Tucson, AZ. Those patients include:
· patients with a neuropathic cause of pain;
· patients with prominent incident pain or pain induced by certain movements;
· patients with cognitive impairment;
· recovering addicts.
"Some recovering addicts may benefit from chronic opioids, but they are also at increased risk of relapse," notes Schneider. n
Resources for Safe Opioid Use
o American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Chronic Cancer Pain. Skokie, IL; 1989.
o Fishbain DA, Rosomoff Hl, Rosomoff RS. Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain 1992; 8:77.
o Melzack R. The tragedy of needless pain. Sci Amer 1990; 262:27.
o Portenoy RK. Opioid therapy for chronic nonmalignant pain: current status. In: Fields HL, Liebeskind JD, eds. Pharmacological Approaches to the Treatment of Chronic Pain: New Concepts and Critical Issues, Vol. 1: 247-287. ISAP Publications: Seattle; 1994.
o Portenoy RK, Foley KM. Chronic use of opioid analgesics in nonmalignant pain: Report of 38 cases. Pain 1986; 25:171-186.
o Porter J, Herschel J. Addiction rare in patients treated with narcotics. New Engl J Med 1980; 302:123.
o Sees KL, Clark EI. Opioid use in the treatment of chronic pain: Assessment of addiction. J Pain Symptom Management 1993; 8:257.
In addition, information and position statements on opioid use are available from the following national associations:
o American Pain Society, 4700 W. Lake Ave., Glenview, IL 60025. Telephone: (847) 375-4715. Fax: (847) 375-4777. E-mail: [email protected]. Web site: www.ampainsoc.org.
o American Academy of Pain Medicine, same address and phone as above. E-mail: [email protected]. Web site: www.painmed.org/default.htm.
o American Society of Addiction Medicine (ASAM), 4601 N. Park Ave., Arcade Suite 101, Chevy Chase, MD 20815. Telephone: (301) 656-3920. Fax: (301) 656-3815. E-mail: [email protected]. Or, in New York: ASAM, 12 W 21st St., New York, NY 10010. Tele phone: (212) 206-6776. Fax: (212) 627-9540.
Here's what to put in opioid use contract
Contracts reduce risk of addiction
Opioids offer safe, effective pain relief for many chronic pain patients. Yet many physicians are reluctant to prescribe opioids due to concerns about patient safety and the potential for addiction. One physician who regularly prescribes opioids for chronic pain suggests case managers put those fears to rest by drafting an opioid contract for use by the patient and physician. (For more information on opioid use in chronic pain, see p. 151.)
"I have all my patients who are on opioids sign a contract," says Jennifer Schneider, MD, PhD, an internist with Arizona Community Physicians and medical director of Kachina Center for Addiction Recovery in Tucson, AZ. "I keep these patients on a very tight leash." Schneider says an effective opioid use contract should include the following:
o Patients must provide old records from all prior physicians.
o They must only obtain mood-altering drugs from prescribing physician or notify prescribing physician in advance of acute needs, if possible. "If the patient is scheduled for surgery or dental work and requires additional pain medication, I want to know," she says. "Patients can be effectively managed for their chronic pain with opioids and still need additional pain medication for acute problems."
"Many surgeons and emergency room doctors are reluctant to prescribe additional pain meds for a patient on opioids for chronic pain. There is a big risk that your patient will be treated like a third-class citizen and be undermedicated for short-term acute pain," she says. "Your job as a case manager is to educate treating physicians about the need for additional pain medication. These patients are not drug seekers. They need relief."
o Patients must have opioid prescription filled at only one pharmacy. Schneider notes even a contract didn't prevent her from being duped by one clever patient. "She suffered from chronic headaches. We agreed that she would receive a prescription for two bottles of an opioid and then see me a one month," she recalls. The young woman appeared to be managing her pain well, showed up for her follow-up appointment, and gave every appearance of being a model patient.
During the third month of treatment, the woman's parents sent Schneider a fax of their credit card bill, which included charges for opioids from 10 different pharmacies. "It turned out she was an excellent record keeper. She used a different pharmacy for each doctor and kept them all straight. She also complied with each doctor's follow-up schedules. We only found out because her insurance was only paying for my services and prescriptions. Her parents were being billed for the others. You can always be duped by a real pro."
Schneider adds that if patients must change pharmacies, they should be required to inform the prescribing physician.
o Patients must not change their dose without prior discussion with prescribing physician. They must understand they will become physically dependent on opioids. "Make sure they understand that they can't let themselves run out," Schneider says. Encourage patients not to take more than the prescribed amount without consulting the prescribing physician, she urges. If your patient notices that the prescription will run out before the end of the month, suggest they count the pills left in the bottle and spread them out over the remaining days.
o No early refills will be allowed, and the prescription will not be replaced if stolen or lost. Schneider has made exceptions to this rule, however. "I had a little old lady with Parkinson's on opioids. She called in tears one day because she had been opening her prescription bottle over the sink and spilled the pills down the drain because her hands were shaking," she says. Schneider refilled the prescription but counseled the patient to open the pills over her bed instead of over the sink.
o Patients must obtain any consultations recommended by prescribing physician. "If there is new pain or another complication that I don't understand, I ask the patient to go back to their original doctor for reevaluation," she says. "We have to find out why the patient needs more meds."
o Patients must abstain from alcohol and illegal drug use.
o Patients must agree to urine drug screens upon request. If your client is employed or applying for a job that requires a drug screen, urge your client to tell the employer upfront that he or she is on opioids. If the employer is uncomfortable about opioid use on the job, provide the employer with position statements from national associations that indicate there is a legitimate place for opioid use, Schneider suggests. (For a list of associations that offer opioid position papers, see box, p. 153.) n
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