Avoiding Opioid Abuse

A fundamental principle in medicine is to do no harm. Practitioners need to know how to prescribe opioids without doing harm – how to treat pain without the fear of contributing to addiction and abuse, how to provide medical pain management in a proper setting that protects the patient, and how to establish an environment and treatment plan that protects the doctor and his or her practice.

There is great demand in the medical community for guidelines on how to properly prescribe opioids and prevent abuse. A majority of this interest has come from the recognition that there is widespread opioid abuse. Substance abuse is a leading cause of preventable illness and death in the United States.¹ The prevailing perception is that substance abuse involves illegal drugs only; however, more Americans abuse medical prescriptions than use cocaine, heroin, hallucinogens, and inhalants combined.² Between 1997 and 2001, in the state of North Carolina, deaths from illegal drugs decreased whereas deaths involving prescription opioids increased 300%.³ In 2002, in the entire United States, controlled prescription drugs played a role in 29.9% of drug-related emergency department deaths (opioids accounted for 18.9% of those deaths).² In 2007, overdose because of opioids caused 11,499 deaths more than heroin and cocaine combined.⁴ Currently, Americans face an opioid abuse epidemic. Americans constitute 4.6% of the world’s population but consume 80% of the world’s opioids. They use 99% of the world’s supply of hydrocodone.⁵

Failing to treat pain is not the answer to preventing opioid prescription abuse. Opioids can be extremely beneficial and positively life altering for patients with intractable pain but are extremely dangerous in the hands of abusers. The goal is to curb abuse and diversion of opioids while maintaining their availability for patients who properly benefit from their use to treat pain. Patients are far more likely to seek treatment for their pain from a general practitioner or other health care provider than from a pain management specialist.

Curtailing Abuse and Diversion

Safe medical pain management using opioids can be accomplished by following this algorithm:

Determine if an opioid is necessary.
If so, prescribe an opioid in a well-informed manner (see chapter on opioids), establish realistic expectations, and have the patient sign a narcotic agreement.
Monitor the patient using regular follow-ups, checking pain management levels and functionality, conducting urine drug screens, and checking the narcotic database regularly.

Determine if the Patient Needs an Opioid

For acute pain in hospitalized patients, the use of an opioid as a first-line agent is reasonable. For outpatients in acute and chronic pain, other first-line agents are available. A patient who presents with pain does not automatically need an opioid. Practitioners can use nonopioids and/or procedures to combat pain before resorting to opioids. It is also appropriate to refer patients to a pain management specialist and not prescribe opioids. Several examples may be illustrative. For arthritis of the knees, a nonsteroidal anti-inflammatory drug (NSAID) or possibly a knee injection may be
effective. For lumbar radiculopathy (sciatica), a neuropathic pain medication and possibly a lumbar epidural steroid injection may be beneficial. For axial cervical or lumbar spine pain, a facet injection may be warranted. For muscle strains, an NSAID or muscle relaxants may work. For fibromyalgia, opioids have never been shown to be helpful. Instead, try a medication approved by the Food and Drug Administration (FDA) for fibromyalgia: Pregabalin (Lyrica), duloxetine (Cymbalta), or milnacipran (Savella). For diabetic peripheral neuropathy, a trial of a neuropathic pain medication on a titration schedule may prove beneficial. For a multimodal approach to multiple pain alignments, physical therapy may be necessary.

If you encounter a patient who wants narcotics only and refuses other treatment modalities, you are under no obligation to prescribe them. If you encounter a patient who was prescribed opioids by another provider and you do not feel that opioids are appropriate for the treatment plan, again, you are under no obligation to prescribe them.

Realistic Expectations, Prescribing Opioids, and the Narcotic Agreement

If the decision to prescribe an opioid is made, realistic expectations should be established. Opioid-based treatment plans are doomed from the start if patients expect to be completely pain free. The goal is to develop a meaningful degree of pain relief and thus improve quality of life. Rarely do patients become pain free – if this is the expectation then the development of a successful, nonabusive therapeutic treatment plan is unlikely. Unreasonable expectations lead practitioners to titrate up to 12 Percocet a day: The opioid is incrementally increased in the attempt to obtain a pain-free state. When the therapeutic relationship inevitably breaks down, the patient is referred to the pain management specialist. This is the classic “pump and dump.”

Before beginning opioid treatment, the physician should completely review the chapter on opioids. Then he or she should discuss the narcotic agreement with the patient, and both patient and provider should sign it. The narcotic agreement is required for patients to be treated for chronic pain or for those needing their second refill on an opioid prescription for acute pain.

The narcotic agreement is critical because it establishes a paper trail that protects both patients and practitioners. It lays out the rules so that patients are clear about what is expected of them. Pain practitioners consider the agreement advantageous because it outlines standards of care, initiating opioid therapy in an atmosphere of mutual trust and full disclosure. The document is an “agreement” rather than a “contract”; the latter implies a stronger legal relationship and suggests a greater obligation. It is important to personalize the narcotic agreement based on the practitioner’s practice and the laws of the state in which it is located. In addition, it should include the following points:

The patient may receive prescriptions for opioids from this practice only and can use one pharmacy only, which must be documented. [This is a critical component of the opioid treatment agreement, mandating that a sole provider control all access to opioids and all opioids come from one pharmacy.]
It is the patient’s responsibility to safeguard medications. Medications may not be replaced if they are lost, damaged, destroyed, left on an airplane, and so on.
Available alternatives to treat pain have been reviewed with the patient and the patient would like to proceed with opioid therapy.
Opioid therapy can result in dependence, tolerance, and/or addiction.
At each medical visit the patient must make a complete and honest self-report of pain relief, adverse effects of treatment, and function.
Aberrant behaviors constituting noncompliance with the agreement include selling or lending of medication, obtaining unauthorized prescriptions, altering prescriptions, using illegal street drugs, and escalating dosages.
Regular appointments must be kept to review the treatment plan.
The patient must consent to random urine drug testing and pill counts.
The patient agrees to waive privacy so that his or her provider may contact other providers to discuss patient care.
The patient must disclose visits to a hospital emergency department and receipt of controlled substances. The patient may receive opioids from the emergency department doctor if that doctor determines that opioids are needed for acute care. However, it is essential that the patient reports this.
A breach of any of these conditions will result in cessation of opioid prescribing and possible discharge from the practice.

It helps to include a statement to the effect that opioids will be prescribed only during normal office hours.

Monitoring Patients Taking Opioids

It is imperative that patients have regular follow-ups. Most practices require that patients taking opioids be seen every 2 months, but the time span can range between 1 and 3 months. At each visit, the provider must check and document three items: Analgesia activity, side effects, and aberrant behavior.

Analgesia Activity

Documentation of the patient’s pain level should occur at every visit. A questionnaire is useful; the patient may complete it upon arrival, before the consultation; it includes a numeric analog scale, with 0 being no pain and 10 representing the worst pain imaginable. The number does not have to be 0 for the treatment to be considered effective – what is important is that the patient has meaningful pain reduction. To determine if pain reduction has been significant, it is essential to ask the following questions:

Is current pain relief sufficient to make a real difference in the patient’s quality of life?
Are activities of daily living improved?
How does current pain level and functional status compare with start of treatment and subsequent visits?

If the patient’s pain level remains a 10/10 on a numeric analog scale with no meaningful pain relief and no increased function despite medication changes, opioid efficacy is highly questionable. In this circumstance, it is important to seriously consider weaning the patient completely off opioids.

In addition, it is essential that the potential for addiction be monitored at all follow-ups. Nonaddicted patients gain function and quality of life if their pain medication is properly adjusted. These patients will reduce the opioid dosage if adverse effects develop. Addicted patients lose function and quality of life with narcotics. Even adverse effects do not cause addicted patients to stop taking their medication.

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