Physicians Offered Guidelines in the Use and Monitoring of Opioid Therapy

Understandably, physicians are cautions about giving their patients narcotics (also known as opioids). Worries about misuse, abuse, and addiction are reasonable. In this article, over a dozen highly qualified panel members offer doctors guidelines for the long-term use of opioid therapy. The target patients are those with chronic noncancer pain (CNCP).

Recent studies have shown that although physician concerns about opioid use are important, it's also true that most patients are able to take these medications without problems. This information has helped open up the use of opioids for chronic pain patients who might otherwise suffer needlessly.

Several tools for clinicians to use in assessing and monitoring patients are provided. The first is the Screener and Opioid Assessment for Patients with Pain (SOAPP). This brief questionnaire helps physicians determine how much monitoring a patient might need who is on long-term opioid therapy.

The second is the Opioid Risk Tool (ORT). Five measures are used to determine a low, moderate, or high risk of problems using opioids. Factors such as personal and family history of substance use, age, history of sexual abuse, and psychological disease contribute to the risk of opioid abuse or misuse.

The third risk assessment tool is called the D.I.R.E. Score. The health care professional completes this tool looking at four main factors. Diagnosis stands for type of pain problem (e.g., fibromyalgia, migraine headaches, back pain) and its natural history (slowly progressive, degenerative).

Intractability looks at what other treatments have been tried, the patient's level of cooperation, and the patient's response to those approaches. Risk is based on multiple variables such as patient reliability, patient's social support, psychologic profile, and use of chemicals such as alcohol or other drugs. And finally, efficacy is assessed, which is a way to score the patient's pain, function, and quality of life.

Once it looks like the patient is a good candidate for opioid therapy, then it's important for the physician to monitor pain management, the patient's response, and results. There are several monitoring tools available to help with this. These tools help the physician determine the risk-to-benefit ratio for each patient. In other words, do the benefits outweigh the risks enough to continue with the drug?

The Pain Assessment and Documentation Tool (PADT) keeps track of pain relief, activity level, and adverse effects of the medications. This checklist also helps the physician (or other health care professional) observe and make note of any potential drug-related behavior.

Another similar monitoring tool is the Current Opioid Misuse Measure (COMM). The COMM is a quick and easy patient self-assessment tool. Patients can still fudge their answers on this survey if they choose to do so. It is designed to be used to see if changes in the treatment plan are needed but it does require the patient's honesty.

Pain management with chronic opioid therapy (COT) requires patient participation and responsibility. They are educated about the proper use of these drugs and required to sign an informed consent form. What's expected of the patient is clearly outlined. Risks of adverse effects are reviewed ahead of time. Goals of therapy and how and when the opioids are to be taken are also clearly described.

Patients must understand that COT rarely provides total pain relief. And it's only one part of a total pain management plan that also includes diet, exercise, behavioral counseling, and stress management.

The treatment guidelines offered in this article cover much more than just patient assessment and monitoring. Choosing the right patient, determining the type and dose of medication, and judging when adverse effects require discontinuation of the drug are important, too. The authors review specific drugs such as methadone, how it works, when to use it, and what to watch for.

COT can be used for high-risk patients (e.g., previous history of drug abuse or mental health problems) and during pregnancy but with frequent and careful monitoring. It's best not to use it during pregnancy, but sometimes the benefit outweighs the risk.

Other concerns such as recommendations for driving and work safety are also addressed. It's not that patients on COT can't drive or work. But if there is any sign of impairment from the medication, they are counseled (for their own safety as well as the safety of others) NOT to drive or engage in dangerous work or recreational activities.

Physicians will be faced with other decisions. What should be done for patients who show drug-related behaviors, who have intolerable side effects of the drug, who make no progress in therapy, or who don't have insurance coverage or a way to pay for treatment? Weaning a patient can be painful but necessary and requires addiction treatment.

Then there's the problem of breakthrough pain. The patient's pain level rises despite usual and standard doses of opioids. Breakthrough pain occurs when the underlying condition is getting worse or when a new, unrelated pain condition is developing. Strategies for approaching this situation are offered. Treatment of the new problem may help. Trying other nondrug treatments is advised before increasing opioid dosage.

Whenever prescribing COT, the physician must be aware of local laws, regulations, and other policies that govern the use of controlled substances. In addition to federal laws, each state has its own regulations that must be followed. Anyone who fails to follow these laws is liable and can be fined or otherwise disciplined.

The panel summarizes the important points of this document by saying first that COT can be used safely and effectively for patients with chronic noncancer pain. The evidence offered in the guidelines is limited but considered the best practice available right now.

Anyone who does not feel qualified to assess, prescribe, and monitor patients should refer them on to a specialist or pain clinic staffed and trained to handle these types of cases. The expert panel agreed that a total management program is needed. No one should just be given opioids without additional nonpharmacologic (nondrug) treatment and social and psychologic support.

Roger Chou, et al. Opioid Treatment Guidelines. In The Journal of Pain. February 2009. Vol. 10. No. 2. Pp. 113-130.



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