Opioid prescribing: An odyssey of challenges
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
Current problems with opioid prescribing, he said, include the fact that the medication may fall into the hands of someone other than the intended patient, the wrong medication may be given for the situation, or the wrong dose or dose formulation may be used.
“We know that prescribing the lowest effective dose would be right, and we need to think about when to stop prescribing,” Dr. Cole said. “If you’ve gone to the dentist for a root canal, you probably take home 30 or 40 analgesic opioid tablets. You maybe took five or 10, but what did you do with the rest? Did you dispose of them in a responsible way? Or did you put them up in the medicine shelf, because you might need them 5 years from now? That’s what happens to a lot of these meds: they become long lived. They just don’t go away. We have to plan with people when we’re going to stop [opioid] treatment, how, and get into the discussion of how to store and dispose of opioids.”
He recommends a stepwise approach to the management of neuropathic pain (Pain. 2007;132[3]:237-51) and noted that many nonopioid agents – including anticonvulsants, antidepressants, antipsychotics, anxiolytics, and lithium – have a role in managing people with chronic pain conditions. For clinicians who elect to prescribe opioids, Dr. Cole recommends defining what the goals are and establishing an exit strategy, so you can say “in case this doesn’t work in 3-4 weeks, or whatever the time frame is, this is what we’re going to do. Discuss the risk-benefit ratio with the patient.”
The least amount of medicine should be prescribed for the shortest period possible. “Review the prescription monitoring program to make sure that no one else is prescribing besides you,” he advised. “It’s an ugly day in your life when you realize you’re one of a dozen people who are prescribing for a patient.”
Dr. Cole noted that there are several potential roles for psychiatrists looking to grow their practice without prescribing opioids, including helping to establish goals of care with colleagues in anesthesia and interventional radiology.
“You can help the decision-making capacity, because not everybody makes great decisions,” he said. “We can certainly identify anxious, depressed, and perhaps even psychotic people, who seemingly get by people in anesthesia, physical medicine and rehabilitation, and interventional radiology. Going a little further, we know how to use adjuvant medication. We can predict adverse events before they happen. Market yourself as being able to help identify at-risk people, either for adverse events from procedures or adverse events from opioid therapy, maybe supervising long-term recovery and negotiating goals for treatment. We need to think of risk as a moving target.”
Not all risk screening tools are the same, he said. The Diagnosis, Intractability, Risk, Efficacy (DIRE) tool, Opioid Risk Tool (ORT), and the Screener and Opioid Assessment for Patients with Pain (SOAPP) best address substance abuse potential among those being considered for long-term opioid therapy.
The Current Opioid Misuse Measure (COMM), the Prescription Drug Use Questionnaire (PDUQ), and the Pain Medication Questionnaire (PMQ) aim to capture the degree of medication misuse or aberrant behavior that characterizes a patient’s opioid use once opioids are started.
The Cut Down, Annoyed, Guilty, Eye-Opener/Adjusted to Include Drugs (CAGE/CAGE-AID); Drug Abuse Screening Test (DAST); PMQ; PDUQ; Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT); Substance Abuse Subtle Screening Inventory (SASSI); and others are more suitable for assessing current alcohol and/or drug abuse than potential for such abuse.
“Don’t forget about urine drug testing,” Dr. Cole said. “Get past the dipstick to order more comprehensive testing if you really want to know what’s going on.”
In his opinion, the success of opioid treatment is indicated by activities such as getting up, showering, grooming, going for walks, and doing household chores. “It is not focusing on your pain intensity,” he said.
Dr. Cole reported that he was a consultant for Mundipharma in 2015.
