Author: Suzanne Novak, MD, PhD
This three-part blog will discuss the use of opioids for chronic pain management. In part I, we discussed evidence and indications for the use of opioids for chronic pain and potential adverse events with use. In part II, we will discuss the ongoing use of chronic opioid therapy (COT), and discuss when and how opioids should be discontinued.
The Role of Opioids in Chronic Pain Management–Part II
In Part II we will discuss the following.
- Steps before starting chronic opioid therapy (COT)
- Steps during COT
- Indications and recommendations for weaning from COT
- Reasonableness of a recommendation of opioids for life in a life care plan
Steps Before Starting COT
As noted in Part I of this blog, opioids are not a first-line treatment for any etiology of chronic pain. This class of drugs is only recommended when all first- and second-line pharmaceutical and non-pharmaceutical treatment options have been tried and failed. Once a physician decides a failure has occurred, these steps are recommended.
- Obtain a complete clinical evaluation. This should include a history and physical, with documentation of baseline assessment of pain and function. Specifics of history of pain (symptoms, triggers, location, and previous treatment) should be documented. Comorbid conditions and medications for those conditions should be included. Look specifically for any history of use of opioids in the acute and subacute phases, and documentation of the efficacy of opioids. Little relief from opioids in earlier phases is a strong predictor long-term use of opioids will not manage pain effectively.
- The clinician evaluating the patient should also look for psychological and psychosocial factors that may predict failure, or past behavior problems with opioids (and other scheduled drugs). These factors include an extreme focus on physical symptoms (somatic symptom disorder), anxiety, depression, post-traumatic stress disorder, or a history of substance use disorder.
- Document the goals of COT , including goals for pain and function.
- Perform a validated opioid risk assessment evaluation. An example is the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP®-R).
- Complete a baseline urine screen for opioids and other scheduled drugs.
- Make the required prescription drug monitoring reports required in multiple states, including Texas.
- Obtain a signed consent or pain management agreement for chronic use from the patient.
Steps During Treatment
- Conduct an initial trial of a short-acting opioid at the lowest effective dose. Doses of most opioids can be compared using tables that convert the prescribed dose to morphine milligram equivalents (MME). The Center for Disease Control (CDC) currently recommends an initial upper limit of no more than 50 MME/day, with a final upper range of 90 mg MME/day. [1]
- Continuously assess the goals previously set for pain and function and measure outcomes to determine if the current goals are being met.
- Conduct scheduled and random urine drug screening and review prescription drug monitoring reports to assure appropriate use of drugs.
Indications and Recommendations for Weaning from COT
Whether to continue COT can be determined with careful assessment of outcomes such as pain and function, and monitoring for adverse events and signs of drug abuse
- If there is (a) no evidence of improvement with opioids, (b) there is evidence of intolerable adverse events, (c) risk of use outweighs benefits, or (d) there is evidence of serious abuse, the clinician should consider weaning the patient from COT.
- Weaning should also be considered if the patient is prescribed drugs that can increase risk of overdose for comorbid conditions (such as benzodiazepines, or other sedating drugs).
- Other reasons for weaning, which may be on a fairly rapid basis, include (a)overdose and/or hospitalization due in part to opioid use, or (b) evidence of an unstable mental health disorder.
- Discontinuation is recommended when there is evidence of illegal activity including diversion, prescription forgery, or stealing.
Recommendations for addressing ongoing treatment in these latter cases should be determined case-by-case, but generally include providing a 30-day supply of medication while transitioning to other care, or while determining the best method for weaning.
The CDC has expressed concern with applying its 2016 recommendations on upper limits of MME to clinical practice for patients who have been on opioids long-term.1 While the goal remains an upper limit of 90 MME/day for all patients, the CDC currently recommends all tapering plans should be individualized. While patients on low dose opioids for shorter durations can be tapered rapidly, patients on higher doses of opioids for longer durations may require slower tapers over several months.[2]
Reasonableness of a Recommendation of Opioids for Life in a Life Care Plan
Multiple issues are associated with the recommendation of opioids for life in a life care plan. Many patients who are now on long-term opioids were prescribed these during a time when treatment with this class of drugs was much more liberal. As noted, the CDC has made recommendations to limit the dose of opioids to no more than a maximum of 90 MME/day (50 MME/day when there is evidence of polypharmacy).1 In patients on doses of opioids higher than these recommendations, consideration of addressing tapering of opioids to a lower dose may need to occur prior to finalizing a plan. A final issue is that opioids are not recommended for patients 65 and older who are at fall risk except for acute pain as they may cause impaired psychomotor function, and/or stumbling, falls, or fainting. They are only recommended with caution in elderly patients who are on polypharmacy.[3]
Summary
Chronic opioid therapy for chronic pain management remains controversial because evidence of efficacy is lacking, and evidence of adverse events from COT is widespread. These blogs hopefully provide some guidance on the role of opioids in chronic pain management, and recommendations for management of COT by clinicians.
[1] Dowell D, Haegerich TM, Chou R CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep 2016 Mar 18;65(1):1-49.
[2] HHS, October 2019. Available at: https://www.hhs.gov/opioids/sites/default/files/201910/Dosage_Reduction_Discontinuation.pdf.. Accessed April 26, 2020.
[3] American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. J Am Geriatr Soc. 2019 Apr;67(4):674-694.
Author
Dr. Novak is a board-certified anesthesiologist and has her PhD in Pharmacy Administration. She is president of Austin Outcomes Research, Inc., a healthcare consulting and utilization review firm with multiple national carriers and legal firms as clients. She is the lead author of the Pain Chapter of the ODG Treatment Guidelines and is a clinical assistant professor at the College of Pharmacy at the University of Texas at Austin where she is active in the Pharmacy Practice Division.