To adequately address pain and best outcomes, a physician must complete a thorough patient evaluation before any treatment plan can be made or medications prescribed. Such an evaluation must include a complete medical history and a physical examination. The physician should make a thorough examination of the patient’s medical record, nature and intensity of the pain, current and past treatments for pain, underlying or co-existing diseases or conditions, the effect of the pain on the patient’s physical and psychological functioning, and history of substance abuse. One or more recognized indications for the use of a controlled substance should be present in the medical record to justify prescribing (WVBM, 2017).
The use of opioid analgesics for other than legitimate medical purposes poses a significant health risk to individual patients and to society. Inappropriate prescribing can lead to drug diversion and abuse by individuals seeking to use opioids nonmedically. It falls to physicians, nurses, and other health professionals to use systematic precautions to minimize the possibility for abuse and diversion of controlled substances (WVBM, 2017).
Prescribers of opioid pain relievers must balance the benefits of these drugs to treat chronic pain against the risks of serious adverse outcomes including addiction, unintentional overdose, and death. Health professionals have an obligation to ensure that these medications are used safely and effectively by their patients to control pain, and to mitigate risks.
The patient evaluation should include most of the following elements:
Clinicians should use caution when prescribing opioids in women of childbearing age, as chronic opioid therapy during pregnancy increases risk of harm to the newborn. Further, opioids should be administered with caution in breastfeeding women, as some opioids may be transferred to the baby in breast milk. When chronic opioid therapy is used for an elderly patient, clinicians should carefully consider the initial dose, titrating slowly upwards if necessary, using a longer dosing interval, and monitoring more frequently. Patients at risk for sleep disordered breathing are at increased risk for harm with the use of chronic opioid therapy. Clinicians should consider the use of a screening tool for obstructive sleep apnea and refer patients for proper evaluation and treatment when indicated (WVBM, 2017).
The FDA requires that extended-release oral forms of pain medications containing hydromorphone, morphine, oxycodone, oxymorphone, or tapentadol; fentanyl and buprenorphine–containing transdermal delivery systems; and methadone tablets or liquid that are indicated for use as pain medicines are subject to a risk management program to ensure that the benefits of a drug for a patient outweigh its risks.
All opioids are powerful medications; however, extended-release long-acting (ER/LA) opioid analgesics contain more opioid than immediate-release formulations, which carries a high potential for accidental overdose, life-threatening respiratory depression, abuse by patient or people known to the patient, misuse and addiction, physical dependence and tolerance, interactions with other medications, risk of neonatal opioid withdrawal syndrome with prolonged use during pregnancy, and inadvertent exposure/ingestion by household contacts, especially children (FDA, 2014).
Research shows the following categories of risk factors for opioid abuse and addiction:
One factor that is strongly predictive of opioid abuse, misuse, or other aberrant drug-related behavior is a personal or family history of alcohol or drug abuse. Although family history of substance abuse and psychiatric disorders are relevant to the appropriateness of opioid pain medications, prescribers should recognize that “a history of substance abuse does not prohibit treatment with extended release opioid analgesics but may require additional monitoring and expert consultation” (FDA, 2014).
When treating chronic pain, healthcare providers must assess the nature and level of patient pain. Common assessment tools include a numeric pain rating scale (0–10), the PEG 3-question scale, the Wong-Baker FACES Pain Rating Scale, and the 20-question Pain Quality Assessment Scale (PQAS). Other useful tools help clinicians evaluate patient risk for adverse effects when considering prescribing opioid analgesics.
These tools allow healthcare providers to ask useful, clinically relevant questions in order to gain a full understanding of the patient before prescribing a potent drug. Here are brief summaries of some assessment tools that healthcare providers can use before initiating opioid therapy:
SAMHSA’s Opioid Overdose Prevention Toolkit recommends that a thorough patient assessment and health history include specific questions. For example:
Further, a patient history should include questions about the patient’s use of alcohol, tobacco, and over-the-counter medicines. Useful screening tools include NIAAA, AUDIT, USPSTF, and ASSIST. Caution must be observed because many OTC medications and alcohol can depress the central nervous system and must not be used in combination with prescription opioid analgesics (SAMHSA, 2016a).
During a physical examination, providers and nurses should also be on the lookout for the following signs in patients being seen for chronic pain:
After a thorough examination, a clinician must develop a written treatment plan. The plan must include goals that can be used to measure treatment success. Goals might include pain relief and improved physical and psychosocial function. The treatment plan should also indicate other diagnostic evaluations or treatments.
Treatment plans should incorporate pharmacologic and nonpharmacologic pain management modalities. Nonpharmacologic therapies may include cognitive behavioral therapy, massage, exercise, multimodal pain treatment, and osteopathic manipulative treatment (WVBM, 2017). The Physicians for Responsible Opioid Prescribing advocate a cautious approach to pain management. They believe that the increased prescribing of opioid analgesics for chronic noncancer pain lacks high-quality evidence to justify the therapeutic change and that, while opioids may provide short-term pain relief, the long-term benefits of opioid therapy have not been established. They advocate that low doses should be considered only for carefully evaluated, closely monitored patients when a structured approach is employed and clear benefits for pain and function are documented. To better educate prescribers about the risks versus benefits of opioids for chronic pain, they have published the Cautious, Evidence-Based Opioid Prescribing, containing do’s and don’ts for acute and chronic pain management (PROP, 2014).
Cautious, Evidence-Based Opioid Prescribing for Chronic Pain