Undertaking opioid therapy for pain in the primary care setting is not an easy task. For this reason I wrote a series of articles for the PainEDU website covering eight different opioid-related conversations that may arise during an office visit.
Without forethought and preparation a clinician may find that these conversations are ‘difficult’ ones to have with a patient.
- – Requests for dose increases when there is no indication the opioid is helpful
- – Behavior that is increasingly irritable, anxious, or labile
- – Advising patients to reduce reliance on pharmacologic treatment
- – When a patient reports lost or stolen medication
- – Urgent calls and unscheduled visits
- – When a patient requests early medication refills
- – When a patient appears intoxicated or somnolent
- – Informing a patient of a positive urine screen for a substance you have not prescribed
Here are principles that I consider to be important to keep in mind as opioid risk mitigation strategies as you set up or evaluate the way prescribing is managed in your practice.
- – As with any medication, decisions about opioid are made with a risk benefit analysis. That fact needs to be shared with the patient at the time of the first prescription, and frequently reviewed at every office visit.
- – Since there is much media attention about opioid risks, this is a wonderful opportunity to revamp your office for safe opioid prescribing. Share this information with all patients as a safety measure to ensure the most effective treatment, given the information that is now available. This is not unique to opioids. – – We have reassessed healthcare practices in the past, for example, hormone replacement therapy in women and different treatments for diabetes and hypertension. Medicine is a constant evolution of what we know that works, and what we know to be safe. Pain treatment is no different.
- – Make sure that all patients review and sign an opioid agreement at the time of the first prescription if there is any thought that this medication will be used more than three months. I actually use an opioid agreement in all patients, even if I am not sure how long they will be on opioids, as it serves as a way to educate patients about the pharmacologic nature of opioids and the risks that may be incurred even with short term use.
- – Do not treat patients with opioids if you are unable to follow them adequately. If your practice is unable to see patients at high-risk weekly or monthly, then these patients should be treated with a non-opioid approach in primary care, with possible opioid therapy left to the specialists. Keep in mind that opioids are not the only treatment for pain; there are many treatments that may be more effective over the long run and infinitely safer. While it is important to address pain it is not necessary to do so with an opioid.
- – Do not be afraid to refer for substance abuse and/or mental health evaluation if this appears to be indicated. Referral is a process, and even if the patient does not take you up on your offer, or seems upset by it, your professional and tactful approach to referral may make it easier for the patient to accept help the next time it is offered.
- – Continue to network with other providers who address the same issues. Our understanding about chronic pain treatment is evolving quickly at this point. Many “difficult” patients are not the patients who show up for evidence based studies; we may know more about what does not work, or is unsafe for them, than what works currently. As we are getting smarter about opioid risks there is no doubt that non-opioid therapies will continue to be developed and will be used not only in patients inappropriate for opioids, but in patients on opioids as well, in order to minimize the dose.
- – It is important to make sure that the patient understands that abandoning opioid therapy does not mean abandoning the patient, or abandoning a comprehensive approach to pain treatment. Opioids may be too risky to warrant use in a number of circumstances. These include comorbid medical problems made worse by opioids, such as respiratory or neurologic problems, comorbid mental health problems, which opioids worsen such as depression or substance use disorder, or lack of improvement on opioids at acceptable doses. Most patients who will have opioids discontinued are not criminals. They are just patients in whom opioids do not represent a safe or effective option for pain control.