ED: Prevent opioid prescribing ‘killing people with kindness’ and where the doctor has problems separating physical addiction from emotional anguish – these notes will help.

In recent years, much as been written about opioid medication in the treatment of chronic pain and its potential harm. The literature regarding opioid efficacy in chronic non-malignant pain comes from short-term RCT studies that tended to have small numbers and were conducted on selected populations over relatively short periods (3-6 months).


Opioids and patients

Demonstrated efficacy is modest, and long-term effectiveness is far less clear. Observational studies have shown that patients with chronic pain who take long-term opioids have worse pain and lower quality of life scores than those who do not.

Dr Richard O’Regan, Next Step Drug & Alcohol Service

We also know that opioid related deaths are increasing worldwide and in Australia the hazard ratio for fatal overdose increases dramatically as the daily morphine equivalent dose increases (HR at 20mg/day or less is 1.0, HR at 50–90mg/day is 4.6, and the HR at > 100mg/day is 7.2.). And we know that opioid addiction with suggestions of loss of control occurs in about 31% of people taking opioids for prolonged periods.

With these issues in mind, when prescribing opioids in the treatment of chronic pain doctors may feel a sense of confusion between wanting to humanely treat pain and yet do no harm to the patient.

Opioid availability may be limited, mainly for patient safety and for public health. The doctor may wonder at aberrant behaviours e.g. self-escalation of dose, multiple early script renewal presentations, “lost” and “stolen” medications, and calls from ED departments or pharmacists reporting drug seeking behaviours. Can we be patient-centred and avoid the pitfalls of prescription abuse and dependence?

The things we can do

It is useful to remember that all chronic pain commences as acute pain, and all long-term opioid prescribing begins as short-term use. Employing a “universal precautions” approach to the use of opioid medication provides a framework for the prescriber by which overuse, addiction and overdose death may be lessened. Here are some ideas:

  1. Explain that opioid medication will not remove all pain, and discuss non-medication components of the management plan (e.g. activity pacing, weight control, physical therapy).
  2. Managing pain includes teaching and supporting the patient to live with the pain while achieving best function possible. This means dealing with the mental health aspects of chronic pain (i.e. depression, anxiety, anger, frustration and loss).
  3. Adopt safer prescribing practices when prescribing opioids in all circumstances, which is difficult because identifying the early features of opioid misuse is hard to do; the Opioid Risk Tool (Webster) may assist -patients at ‘moderate risk’ warrant background checks with the Medicines and Poisons Regulations Branch (9222 6883) or the Prescription Shopping Information Service (1800 631 181), while those at ‘high risk’ should be discussed with an addiction medicine or pain specialist.
  4. Consider a treatment agreement – issues such as dosing limits, remaining with a single prescriber, scripting boundaries and appointment attendance.
  5. Monitor for opioid overuse e.g. early requests for repeat prescription, self-escalation of dose, or attending other doctors for additional medication. If overuse is occurring, restrict access by increasing the frequency of medication collection (i.e. to weekly, twice weekly, or daily pickup). While unpopular with patients, staged dispensing may address the issue of loss of self-control, and will reduce the impact from medication loss, theft or bartering for other drugs.
  6. Consider urine drug screening to monitor for illicit drug use that might harm patients. If detected, liaise with an addiction medicine specialist.

Enhancing the patient’s confidence to cease opioid use is important and may be achieved by discussing and normalising the process. Describe opiate withdrawal, and make sure the patient is aware that small dose reductions, say weekly, will minimize the effects (otherwise, abrupt opioid cessation causes discomfort so the patient avoids further de-prescribing efforts).

References available on request.

Questions? Contact the editor.

Author competing interests: nil relevant disclosures.

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