Pain Management in an Opioid Epidemic: What’s Appropriate, What’s Safe

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Tools and strategies for appropriate use of opioids

There are tools and strategies available to ensure proper use of opioids for managing chronic noncancer pain. Urine drug testing, screening tools for opioid abuse, prescription drug monitoring programs, and opioid treatment agreements should be considered for patients who require prescription opioids to treat pain.15

Urine drug testing. The CDC recommends that prescribing clinicians perform urine drug testing before initiating opioid therapy and at least annually afterward. It can be used to assess for prescription medications generally, controlled prescription drugs specifically, and substances of abuse.16 Urine drug testing can mitigate the risk for misuse or overdose of opioids, as well as identify patients who were prescribed an opioid but are not taking it. The prescribing provider is responsible for explaining to the patient why urine testing is being done, performing confirmatory testing, and discussing results with the patient.

Risk-assessment tools. A number of web-based tools help the prescribing provider assess a patient’s risk for misuse or abuse of opioids and other substances. They fall into three general categories of use: assessing patients being considered for long-term opioid therapy; assessing for misuse once opioid treatment is initiated; and addressing the potential for substance abuse generally.17-24 Table 2 lists examples. Although screening tools are not 100% accurate at identifying who is a substance abuser, they do alert the provider that a potential problem exists and needs to be explored. As such, they should be considered one component of comprehensive risk assessment, monitoring, and mitigation.25

Tools to Assess Risk for Opioid Misuse/Abuse image

Prescription drug monitoring programs (PDMPs). NPs and PAs must also be aware of “doctor shopping,” in which a person seeks prescriptions from multiple providers (often under false pretenses) and has them filled at multiple pharmacies. ­PDMPs are designed to monitor for suspected abuse, diversion, or inappropriate prescribing. These state-run electronic databases track the amount of controlled substances prescribed, dispensed, and refilled for a given patient.26 This information can assist providers in identifying high-risk patients who may benefit from an early intervention program.27 Once a patient is identified as having an opioid use disorder, NPs and PAs must provide appropriate referral to an evidence-based practice for treatment of abuse. It is essential to recognize that an opioid use disorder is a chronic illness and that relapses occur.

Opioid treatment agreements. These have been presented as a strategy to prevent prescription drug abuse; however, there is little evidence to support their effectiveness in preventing medication misuse, abuse, or diversion of opioids. In fact, research has shown that such agreements can put the patient–provider therapeutic relationship at risk for disruption, since patients may feel mistrusted or stigmatized by the suggestion that they might behave inappropriately.28 The position of the American Pain Society and the American Academy of Pain Management is that patients and clinicians should have ongoing discussions about chronic opioid therapy that include goals, expectations, risks, and alternatives to opioids.29 If a written agreement is used, it needs to address the patient’s and the clinician’s responsibilities and expectations in managing chronic pain.28

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