10 Tips for Opioid Prescribing

This is a “between a rock and a hard place” situation for most of us. To bring this crisis under control, physicians must prescribe more cautiously. For this to occur, we need education that is free of industry bias. Rheumatologists are the caregivers for many patients with significant pain. Chronic non-cancer pain is a serious problem, and opioids may not be the answer. Chronic pain patients deserve compassionate, pain-relieving care and evidence-based treatment.

What’s a Clinician to Do? 10 Points to Consider

There are a variety of tools that can form the basis for your care of patients on chronic opioids. Each patient is different. Acute vs. chronic opioids for a given diagnosis and patient depends on complex factors, including their familial and personal risk factors for substance misuse, as well as their response to alternative therapies.

All of the following recommendations are addressing chronic pain that is not related to cancer. And all of these suggestions would have been helpful in both of the aforementioned actual cases.

1 Start with a thorough evaluation. Are you sure about the cause of the pain? Is further workup indicated? Is this a disease for which opioids are indicated? Make sure the diagnosis is right.

2 Calculate and document the MED from all sources every visit. One hundred and twenty mg/day morphine equivalents are considered dangerous and more likely to lead to unintended deaths. If the patient’s dosage exceeds 120 mg/day, consider referring the patient to a pain specialist. If the patient is not getting at least a 30% improvement from the opioids, consider alternatives.

3 Try other medications first. In the case of zoster or neuropathy, can you try neuropathic medication, such as neurontin or serotonin norepinephrine reuptake inhibitors (SNRIs)? Are NSAIDs worth a try? If the diagnosis is fibromyalgia, opioids probably represent more risk than benefit.

4 Assess risk of abuse. Evaluate the patient for coexisting psychological problems or prior addiction issues. Consider the patient’s family history and history of abuse, because these factors will make the patient a higher risk for addiction. Evaluate concomitant use of benzodiazepines and sleep aids. These are extremely high risk when used concomitantly with opioids.

5 An informed consent is indicated when using opioids chronically. What are the risks and benefits of long-term usage? Always warn the patient about the problem of polypharmacy and concomitant usage of other pharmaceuticals, alcohol or marijuana. Remember to discuss hypogonadism, operating heavy machinery, falls and driving.