Opioids safe, effective for chronic pain relief
Case managers must educate physicians on use
Physicians often are reluctant to prescribe opioids for chronic pain because they've been trained that opioid use leads to addiction and that chronic use is intrinsically bad. Patients are just as reluctant to take them for the same reasons. However, the truth is that appropriate use of opioids is an effective and inexpensive way to relieve chronic pain in many patients.
Case managers may have to do a "selling job" on patients and employers as well as physicians, says Jennifer P. Schneider, MD, PhD, an internist with Arizona Community Physicians and medical director of Kachina Center for Addiction Recovery in Tucson, AZ. "I had one young man who was very concerned about being on methadone for the rest of his life," she says. "Patients, families, and employers often fear opioids. They think they are dangerous. They believe the patient will be unstable and may possibly become addicted.
"Much of what I do in the beginning is education. There is actually a very low risk of addiction when opioids are used appropriately," she says. "Case managers are strategically placed to facilitate the appropriate use of opioids. These meds end up costing insurance companies less money than other analgesics. And because they are more effective in relieving pain, your patients don't end up in the emergency room looking for pain relief. They also can get back to work."
Case managers may need to educate physicians about opioid use and assure them that prescribing opioids will not get them in trouble with their state licensing boards, says Schneider. There are several steps she takes to protect her own medical license. Those include:
· thoroughly assessing patients before prescribing opioids;
· carefully documenting patient assessments and prescribing information;
· seeing patients frequently.
Schneider sees her chronic pain patients weekly at the beginning of opioid treatment and then monthly. At each visit, she prescribes only enough medication to last until the next appointment. In addition, she assesses and carefully documents the following:
· effectiveness of analgesia;
· emergent side effects;
· functional status;
· aberrant drug-related behaviors.
"If the patient demonstrates some possibly aberrant behaviors, you must determine whether this is due to opioid addiction or some other cause, such as psychiatric disorders, a family disturbance, or criminal intent, such as selling the prescription drug on the street," says Schneider. "Patients may also experience 'pseudo addiction.' This is not a true addiction, but rather a sign that the patient is inadequately treated. When you have severe pain, it pushes everything else out of your head. Medication relieves that pain to the point where you can resume your life. Patients who are inadequately treated may exaggerate their pain to get more meds."
Dependence is not addiction
Chronic pain patients do develop a physical dependency on opioids, but case managers should not confuse dependency with addiction, Schneider says. "Physical dependence is a characteristic of opioids. It means that a habituated user will experience certain symptoms if the drug is stopped abruptly."
Opioid withdrawal symptoms include:
· anxiety,
· nausea and vomiting,
· irritability,
· abdominal cramps,
· insomnia.
"All of those symptoms can be avoided by tapering," Schneider says. "Longer-acting drugs such as methadone have a slower onset of withdrawal symptoms and are associated with less severe symptoms than shorter-acting drugs such as morphine," she adds.
Addiction is a psychological and behavioral disorder, she explains. An addicted patient may exhibit "drug-seeking" behavior and need to use the opioid for effects other than pain relief. To assess possible addiction, Schneider looks for the following during each patient visit:
· unreliable drug-taking behavior, such as changing doses without consulting the doctor;
· loss of control over prescription use, such as using up the drug before time for the next refill;
· drug-seeking behavior, such as frequently reporting losing the drug and needing more;
· abuse of drugs other than prescription drugs;
· contact with street drug culture, such as selling prescription drugs and buying street drugs;
· negative consequences resulting from drug use.
"Opioids should enhance the quality of life for chronic pain patients," Schneider says. "If I'm in doubt about whether the patient really needs a higher dosage to achieve adequate pain control, I tend to give the patient the benefit of the doubt. If the patient is really out of control, it will become apparent soon enough."
The first step to appropriate pain management is a thorough assessment of the patient, she notes. "You have to know the goal of treatment," she says. "Is it possible to determine the cause of pain and eliminate it? A patient with severe hip pain due to osteoarthritis might be better served by undergoing a hip replacement, which might result in no pain and improved function. Opioid management is appropriate only if the goal of treatment is pain relief, not cure." (For discussion of which patients benefit most from opioid treatment, see above box.)
Schneider says a thorough assessment of the patient should include the following:
o Pain assessment. Physicians and case managers must rely on the patient's self-assessment of chronic pain, she notes. Some questions that help determine the level of a patient's chronic pain include these:
1. On a scale of one to 10, with 10 being the most severe, how severe is your pain now?
2. How severe is pain usually?
3. What kinds of medications, and how much, does it take to relieve your pain?
"Patients have learned that unless they say their pain is an "11" on a scale of one to 10, doctors won't prescribe them adequate pain relief," Schneider says. "Once I assure them that I won't take their medication away if they are honest with me, I usually get a fairly honest self-assessment of pain from my patients."
Chronic pain becomes independent of the original injury, but it is still helpful to understand how the pain began, she says. And it's important to assess how pain has affected the patient's quality of life. "It's also important to document quality of life, because one of the important facts differentiating addiction from dependency is that addiction constricts one's life, whereas appropriate opioid use enhances it by improving function," Schneider says. "This makes it important to be able to compare what happens to the patient's life once opioid use begins."
o History of past treatments. "Although very effective when properly used, opioids are still a last resort," she says. "Before prescribing opioids, I determine whether all other appropriate therapies have been tried." Those therapies include the following:
· non-opioid analgesics;
· tricyclic antidepressants for neuropathic pain;
· full-dose antidepressants;
· physical therapy;
· biofeedback;
· anticonvulsants for neuropathic pain;
· hypnosis;
· surgical procedures to relieve pain.
o Addiction history. This should include both personal and family history of alcoholism and other addictions. "It should also include personal history of alcohol, smoking, and other drug use," Schneider says. "In addition, you must assess the patient's willingness to abstain from use of alcohol and other mood-altering substances during opioid treatment." (Abstaining from alcohol use is part of Schneider's standard patient contract. For other conditions of the contract, see p. 154.)
The patient also should be asked about past opioid experience, she says. "If there was a history of lost prescriptions, medications from more than one doctor, or demand for early refills, I probably would not consider the patient appropriate for opioid therapy. This is another reason it's useful to have the patient's old records, to learn what other doctors' experience was with the patient."
If the patient seems to be an appropriate can didate for opioid therapy, Schneider says it's important to start with a low dose and increase it gradually. "We start low because the meds do have side effects. If you start with a low dose, patients develop a tolerance to the sedation, nausea, and respiratory effects of narcotics. They become less sedated with the same dose and can even safely drive and operate machinery."
The good news is that although patients adjust to the sedation and nausea caused by opioids, they don't develop tolerance for the pain relieving effects of the opioid. In addition, opioids cause constipation, so it's important that case managers make sure chronic pain patients on opioids have a bowel program. "I recommend they use [daily fiber therapy] and ask them about constipation at every office visit," says Schneider.
For chronic opioid use, Schneider prefers long-acting drugs such as methadone. "Methadone has several advantages. First, it's very inexpensive, which makes it great for Medicare patients or others with a limited income." Other advantages of long-acting opioids include these:
· lower street value;
· less severe withdrawal;
· less risk of liver toxicity.
"Many commonly prescribed analgesics contain acetaminophen, which in doses of more than three grams a day, or the equivalent of 12 regular Tyle nol, carry a risk of liver toxicity," says Schneider. "Although, patients, families, and even physicians have a fear of opioid use, opioids are one of the safest drugs around. The only time they are not safe is when dosages are increased too rapidly. If you start slowly and increase gradually, there is virtually no ceiling to safe opioid use."
Schneider says case managers should not be concerned if chronic pain patients on opioids experience more pain after the first few weeks of therapy. "What often happens is that for the first time, they actually feel better, so they increase their activity levels. It's because of their increased activity that they feel more pain," she says. "I ask them what they've been doing and carefully document their reported activity in the chart. Then, when I increase the dose, everything is covered."
In addition, case managers should not throw in the towel if their patient doesn't respond well to the first opioid prescribed. "A patient who doesn't do well on one opioid may do fine on another," she says. "For example, methadone is metabolized at very different rates in different patients. For example, patients on anti-seizure meds may meta bolize opioids at a very rapid rate and may not achieve adequate pain relief."
Long-acting opioids give a smoother blood level and less mood alteration and are preferable to short-acting opioids, Schneider says. If your patient does not achieve adequate pain relief from the first opioid prescribed, suggest the physician consider a longer-acting drug, she says.
If physicians, patients, or employers question the appropriateness of opioid use or the safety of working while under opioid therapy, case managers should provide them with position papers about opioid use from national organizations, she suggests. (For a list of resources, see p. 153.) "If nothing else, the employer will see that medical organizations recognize that there is a legitimate place for treating patients with these medications. In general, if a patient on opioid therapy is behaving normally, then it is safe to assume the patient can perform work tasks safely."
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