Using Oral Opioids for Noncancer Pain: Guideline for MDs

[Guest guest]

Sandy,

You wrote, " He told me the strongest pain medication out there that can be

prescribe is the percocet 5's that I have. "

This is an article written by a pain doctor regarding the use of Opiods in

noncancerous pain, such as pancreatitis. IT may help answer some of your

questions.

Karyn E. , RN

Executive Director, PAI

http://www.pancassociation.org

Pancreatitis Association International

SPPM Note: The use of oral opioids in the treatment of chronic benign pain has

been a difficult and controversial issue for physicians who treat pain. Dr.

's paper does an excellent job in covering how to safely prescribe oral

opioids for these patients.

Using Oral Opioids for Noncancer Pain: How to Relieve Pain and Protect Your

License.

H. Rand , M.D.

Chief Medical Officer

Newport Pain Management Medical Corporation

On a daily basis, pain practitioners make patient care decisions that affect the

lives of our patients. The choice of prescribing oral opioid agents for

noncancer pain is one that affects not only your patient, but potentially your

own livelihood as well.

Indeed, opioid analgesics are considered the cornerstone of treatment for pain

associated with trauma, surgery, medical procedures, and cancer. Thus, there is

little controversy regarding opioid prescriptions for these conditions. However,

it is important to recognize that inappropriate prescribing of controlled

substances, including the opioids, can lead to drug abuse and diversion.

Inappropriate prescribing can also lead to ineffective management of pain,

unnecessary suffering of patients, and increased health care costs.

Although the prescribing of opioid analgesics for other patients with

intractable non-cancer pain may be beneficial, especially when efforts to remove

the cause of pain or to treat it with other modalities have been unsuccessful,

the physician must follow recognized guidelines regarding their use. While these

guidelines may vary from state to state, a physician that adheres to these

principles should remain in good standing with any medical board.

General Good Practice Guidelines

Each of the following items listed below are essential items that a medical

board will evaluate in determining whether a physician is prescribing opioids

within standards of medical care.

1. Documentation of a History and Physical Examination:

While this sounds so basic, it is often one of the most neglected. Your report

should include an assessment of the pain, physical and psychological function,

substance abuse history, and assessment of underlying or coexisting diseases or

conditions. It should also include the presence of a recognized medical

indication for the use of a controlled substance.

Documentation of the patient's pain level can be made by detailing the

chronology and symptomatology of the presenting complaint. The data should

include information about the onset, quality, intensity, distribution, duration,

course, and affective components of the pain. Also include details about

exacerbating and relieving factors. Additional symptoms (e.g., motor, sensory,

and autonomic changes) should be noted. Information regarding previous

diagnostic tests, results of previous therapies, and current therapies should be

reviewed. This can be accomplished by having a prescreening questionnaire filled

out before the appointment, as well as a template for questioning during the

actual exam. Having the patient diagram the intensity and location of the pain

on a pain homunculus at the initial visit can be very helpful.

The physical examination should include an appropriate, directed neurological

and musculoskeletal evaluation, with attention to other systems as indicated.

Not only the cause(s) of the pain, but also the effects of the pain, such as

physical deconditioning, should be evaluated and recorded.

The psychosocial evaluation should include substance abuse history. Information

about the presence of psychological symptoms (e.g., anxiety, depression, or

anger), psychiatric disorders, personality traits or states, and coping

mechanisms should be listed. Evidence of family, vocational, or legal issues,

and involvement of rehabilitation agencies should be noted. The expectations of

the patient, significant others, employer, attorney, and other agencies (e.g.,

Workers' compensation, Social Security Administration) also should be

determined.

2. List your impression, differential diagnosis, and plan:

Medical boards want to know if the opioid treatment fits the diagnosis. Be as

specific as you can in listing your diagnosis, but don't be afraid to list a

proper differential diagnosis.

The treatment plan should state objectives by which treatment success can be

evaluated, such as pain relief and/or improved physical and psychosocial

function, and indicate if any further diagnostic evaluations or other treatments

are planned. You are expected to tailor drug therapy to the individual medical

needs of each patient. Document that these treatment and outcome goals were

discussed with the patient.

3. Document informed consent for opioid use:

You should discuss the specific risks, benefits, and alternatives for the use of

opioids with your patient or their guardian. Discuss the appropriate way to

document this discussion with a risk management specialist, such as your

malpractice carrier.

Many physicians use an informed consent form, that in addition to detailing the

risks, also has the patient agree to other stipulations, such as:

That only you will prescribe controlled substances for their painful conditions.

That they agree to use only one pharmacy.

That the patient must keep their current address on file with your office.

That no emergency refills for " lost " prescriptions will be given.

That random urine screening for substance use may be ordered.

4. See the patient regularly for follow-up:

You should periodically review the course of opioid treatment of the patient and

any new information about the etiology of the pain. Typically, no more than a

thirty-day supply on opioids is written, and it is therefore reasonable to see

the patient every month. Have the patient keep a pain diary, and record reports

of side effects associated with pain management. Perform and document a focused

physical exam. Include assessment of the patient's mental status when

appropriate.

A medical board will want to see documentation that continuation or modification

of opioid therapy was based on your evaluation of the patient's progress toward

treatment objectives. If the patient has not improved after starting opioids,

you should assess the appropriateness of continued opioid treatment and/or a

trial of other modalities. Address the reason for any early medication

refills-are you undertreating, is the patient tolerant, is the pain changing, or

are there signs of addictive behavior.

5. Refer for appropriate consultations:

Refer your patient to the appropriate specialist to help meet the diagnostic and

treatment goals outlined in your treatment objectives. Be quick to refer

patients to addiction medicine specialists if you have information to suspect

they are at risk for misusing the opioids. Also be wary of those whose living

arrangements pose a risk for medication misuse or diversion.

Some states, such as California, require that a patient be seen by at least two

physicians if opioids are to be used. Documenting a curbside consult with a

group partner can be a win/win scenario, as the partner has no additional

liability, and you get the benefit of documenting a second opinion.

6. Keep complete records:

Document everything discussed. Keep copies of your phone conversations, and of

each prescription you write.

Obtain copies of records from past treating physicians.

Obtain copies of appropriate studies and lab values.

Obtain reports from concurrent treating physicians.

Send copies of your reports to all of the patient's current treating physicians.

7. Know the state and DEA prescribing regulations:

It goes without saying that you should follow the DEA and state rules when

writing prescriptions. If you intend to dispense opioid medications from your

office, be especially vigilant. The financial benefit may not be worth the risk

if all documentation is not in order.

8. Follow sound pain management principles:

Use long-acting opioids for chronic pain. Short-acting " breakthrough " opioids

should be needed no more than three times a day, if at all.

Use appropriate adjuvant analgesics such as antidepressants,

membrane-stabilizing agents, and NSAIDs to limit opioid need.

Use blocks, TENS, physical therapy, psychological counseling, and biofeedback as

appropriate to the diagnosis.

Some practitioners will attempt to decrease the opioid dose by 25% on occasion

to see if the patient can maintain activities at that level.

9. Keep yourself up to date:

Attend pain conferences, give local grand rounds, and read relevant articles. A

medical board wants to know that you have a sound knowledge base regarding the

complications that can occur when prescribing long-term opioids.