Safe Opioid Prescribing: A Long Way to Go

Excerpt

Chronic pain is one of the most common reasons why patients visit a physician; yet, physicians are poorly trained to manage it. Despite centuries-long therapeutic use of opioids for pain, they fell out of favor for most of the 20th century in the US. However, in the 1980s, medical literature began to support the practice of prescribing opioids for chronic non-cancer pain.1 Opioid prescribing then escalated over the past two decades,2 despite lack of strong evidence supporting this practice.3 Although it started as an antidote to under-treatment of pain, increased opioid prescribing has paralleled increases in opioid misuse including overdoses, diversion and addiction.4,5. Over the last decade, the medical and public health communities have begun to address this problem by cautioning that all patients prescribed opioids carry some degree of risk for opioid misuse. Recent clinical guidelines based on expert consensus now endorse universal assessment for opioid misuse risk and monitoring for subsequent potential harm.6‐8 The guidelines suggest that patients at “high risk” for misuse should be identified through individual patient risk factors, such as an existing diagnosis of substance use disorder (SUD), mental health problems, history of legal problems and younger age. Treating chronic pain with opioids should include monitoring for harm including urine drug testing to detect any illicit substance use and whether the prescribed opioid is being taken , frequent prescriber visits, pill counts to evaluate adherence with opioid dosing and to minimize diversion, use of state prescription drug monitoring program data, when available, and addressing aberrant opioid taking behaviors9,10 such as patients requests for early refills. More intensive monitoring is recommended for those with more risk factors. When necessary, physicians should also refer patients to adjunctive mental health or addiction treatment specialists for co-management, when such services are available. …