Best Practices for Prescribing Opioids and Recognizing Pain, Drug Diversion, and Substance Abuse

Contact Hours: 3

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Contact Hours: 3

This online independent study activity is credited for 3 contact hours at completion.

Course Purpose

To provide healthcare providers an overview of pain, opioid use disorder, and current practices in prescribing controlled substances.

Overview

One of the single most difficult challenges for any prescriber is to distinguish between the legitimate prescription of controlled substances and the prescription potentially used for illegitimate purposes. To differentiate between the two, prescribers need to understand the signs, symptoms, and treatment of acute and chronic pain, as well as the signs and symptoms of patients using controlled substances for non-legitimate purposes. This learning topic provides an overview of pain, opioid use disorder, and current practices in prescribing controlled substances.

Objectives

Upon completion of the independent study, the learner will be able to:

  • Define controlled substances and drug use disorder.
  • Distinguish between drug misuse and drug use disorder.
  • Explain the Controlled Substance Act, the various classifications of scheduled drugs, and drugs that are most likely to be misused.
  • Describe drug seeking behaviors and possible treatment options.
  • Discuss guidelines for safe prescribing of drugs.

Policy Statement

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Disclosures

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.

Fast Facts: Prescribing Opioids

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Case Study

This online independent study activity is credited for 3 contact hours.

You are working in the triage area of your local emergency room. A 25-year-old male presents with a complaint of severe abdominal pain. When obtaining his health history, he says that he was recently discharged from the hospital after being in a “really bad car accident where someone died”. You review his health record and note that he was previously admitted to the hospital for a prolonged period, had multiple surgeries, and required a patient-controlled analgesia (PCA) pump. However, that admission was one year ago. You also note through medication reconciliation of his health record that he has had multiple prescriptions for Vicodin. During his last emergency room visit one week ago, he was administered both hydromorphone, and meperidine for a complaint of severe abdominal pain, and provided a prescription for Vicodin. You inquire about his prescriptions, and he said “They only give me a little bit of the Vicodin, but I’d rather have the Dilaudid because I think I’m allergic to everything else. Everything else makes me sick and throw up, and the Dilaudid is the only thing that helps me with the stomach aches.” Is this patient susceptible to drug use disorder? What is the difference between drug use disorder, and misuse of a drug? If you were to write a prescription for medication, what parameters should the prescription include? If you do suspect drug use disorder, what resources could you provide to the patient? These questions will be answered as you progress through this independent learning activity.

Introduction

One of the single most difficult challenges for any prescriber is to distinguish between the legitimate prescription of controlled substances and the prescription potentially used for illegitimate purposes. To differentiate between the two, prescribers need to understand the signs, symptoms, and treatment of acute and chronic pain, as well as the signs and symptoms of patients using controlled substances for non-legitimate purposes.⁶˒⁷

Relief of pain is a common reason people seek the care of medical professionals. While many categories of pain medications are available, opioid analgesics are FDA-approved for moderate to severe pain. As such, they are a common choice for patients with acute, cancer-related, neurologic, and end-of-life pain. The prescribing of opioid analgesics for chronic pain is controversial and fraught with inconclusive standards.

Opioid analgesic prescribing was expanded in the 1990s as a result of the failure of health professionals to treat severe pain. Increased prescribing led to increased overuse, drug diversion, opioid use disorder, and overdose. The “Catch-22” seems to be either health professionals undertreat, and there is needless suffering, or they overtreat, with a potential to cause adverse effects like increased opioid analgesic use disorder and potential overdose.

Perhaps the biggest challenge of caring for patients with pain is that individuals have different levels of tolerance and require variable opioid doses to obtain adequate pain relief. Patients may have a range of behavioral, cultural, emotional, and psychologic responses to pain versus a substance use disorder, and often it is difficult to tell the difference. All health professionals who are engaged in pain management must understand the treatment recommendations and safety concerns in prescribing opioid analgesics. Appropriate opioid prescribing requires a thorough patient assessment, short and long-term treatment planning, close follow-up, and continued monitoring. All providers need to be aware of not only appropriate patient assessment and treatment planning but also the possibility of use disorder, diversion, and potentially dangerous behavioral responses to controlled substances.

Many clinicians know little about opioid use disorder. They do not understand that it is a disease, and many believe opioid dependence is the same as opioid use disorder. Lack of a clear understanding can result in clinicians confusing a chronic pain patient and one who is misusing their prescribed opioid. Lack of training and educational deficits often interferes with the appropriate prescription of opioid analgesic agents. To prevent misuse of controlled substances, providers that prescribe controlled substances should learn prescribing practices that minimize or prevent adverse consequences. ³

Definitions
Addiction: According to the American Society of Addiction Medicine (ASAM) – Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biologic, psychologic, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward or relief by substance use and other behaviors. Addiction is now termed “use disorder,” and is characterized by an inability to consistently abstain, craving, impairment in behavioral control, diminished ability to recognize significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, use disorder often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, use disorder is progressive and can result in disability or premature death.” ¹¹
Appropriate opioid prescribingProviding pain control while minimizing use disorder or risk of use disorder and toxicity.  Implementing safeguards to reduce drug diversion.
Inappropriate opioid analgesic prescribingExcessive, inadequate, or continued prescribing despite evidence of the lack of effective opioid treatment.
Controlled substancesDrugs or medications that possess the potential for being misused and are considered to be substances that have a substantially high risk of resulting in substance use disorder.
NarcoticsComes from the Greek word for stupor and originally referred to drugs that dulled the senses, relieved pain, and induced sleep. Please note that the Drug Enforcement Administration (DEA, USA) uses the term narcotic to refer to drugs that are opioid analgesics.
Pain

Course Purpose

Pain is among the primary reasons that people receive federal and private disability payment support. Pain syndromes affect as much as 50% of the United States population at some point in their lifetime. For those over 21 years of age, approximately 10% have experienced pain for 3-12 months, and almost 50% have had pain longer than one year. Nearly half report their pain is uncontrolled. Over 5 million Americans are receiving long-term opioid analgesics for chronic pain. For many of those, the pain is disabling.

Before 1990, physicians rarely prescribed opioids for noncancer pain. Starting in the 1990’s physicians were encouraged to control pain as this was the “fifth vital sign.” The use of opioid analgesic pain medicine increased substantially. There is now agreement that overprescribing of opioid analgesics occurs but is still unclear in the literature where this takes place and the exact circumstances when prescriptions are inappropriate. There has been a drastic reduction in opioid analgesic prescribing and overdose, but it has also resulted in sometimes making it difficult for patients with legitimate pain to receive pain relief. For some individuals, these barriers have resulted in increased difficulty finding health professionals willing or able to prescribe pain medication. For instance, a patient with an acute injury may require scheduled drug treatment. Likewise, for some patients, the acute pain experienced may become a chronic ailment.

Pain can be the result of neurologic and musculoskeletal conditions or be local or systemic as a complication of disease. ¹² Chronic pain syndromes have associations with many long-term conditions and diseases. Common causes of pain include:

Neurologic and Systemic Diseases

AlcoholismAnkylosing spondylitisBrachial plexus traction injuryCancerComplex Regional Pain Syndrome
Diabetic polyneuropathy  DrugsFibromyalgiaGiant Cell ArteritisGlaucoma
InfectionsMigraineOsteoarthritisOsteomalaciaPernicious anemia  
Polymalgia rheumatica  PolyneuropathiesPolyradiculopathiesPostherpetic neuralgiaRheumatoid arthritis
Side effects of chemotherapy or radiation therapy  Sjogren syndromeSpinal stenosisSystemic lupus erythematosus (SLE)Smoking
Temporomandibular joint dysfunctionThoracic outlet syndromeTrigeminal neuralgiaThyroid disease 

Musculoskeletal Causes of Pain

Ankylosing spondylitisChronic overuse  DislocationsFracturesMechanical back injury
Muscular StrainsMyofascial diseases  OsteoarthritisOsteomyelitisOsteoporosis
Polymyalgia rheumaticaPolymyositisRheumatoid arthritis  

Psychological Causes of Pain

AnxietyDepressionEmotional disordersPersonality disordersSleep disorders

Any of the above conditions and causes of acute pain may progress to chronic pain. When there is chronic use of pain medicine, the risk of developing opioid use disorder to control the pain increases. Risk factors for a use disorder to a pain medication include beginning drug use at a young age, previous history of illicit drug or alcohol abuse, family history of illicit drug or alcohol abuse, sexual abuse in females, adverse childhood experiences, and psychological comorbidities, such as depression, bipolar disorder and attention deficit hyperactivity disorder. ⁶ Providers should carefully evaluate and treat patients for short acute pain syndromes and use opioid analgesics at the appropriate dose and only on a short-term basis. Those patients requiring long-term pain control should obtain a referral to a pain management specialist.

Pain Pathways

Opioids bind to receptors in the central and peripheral nervous systems (primarily delta, kappa, and mu receptors), and produce therapeutic effects for pain, cough, and diarrhea. The action on these receptors produces intense euphoria. The euphoria causes some people to continue use drugs with the intention of recreating th first experience of feeling high. Most people who misuse opioids do so for pain relief or to prevent withdrawal symptoms.

Below are receptors and their physiologic effects on the central nervous system:

Delta Analgesia, antidepressant, convulsant, physical dependence, modulate mu-related respiratory depression
Kappa Analgesia, anticonvulsant, depression, hallucination, diuresis, dysphoria, miosis, neuroprotection, sedation
Mu Analgesia, physical dependence, respiratory depression, miosis, euphoria, reduced GI motility, vasodilation. Peripheral mu receptors are tissue-specific with higher concentrations in bronchial smooth muscle and the digestive tract. This is the reason for opioids suppressing the cough reflex and causing constipation. ¹²

Withdrawal symptoms most often occur when opioids are discontinued abruptly. Withdrawal symptoms may present in acute, subacute, and chronic phases. Most healthcare providers are aware of the acute withdrawal symptoms that include hot/cold flashes, nausea, vomiting, diarrhea, sweating, lacrimation, insomnia, anxiety, generalized muscle pain, and tachycardia. However, many providers do not have much experience with the prolonged subacute chronic phase.  The symptoms of the subacute chronic phase can sometimes come and go with wave-like re-occurrences in severity of symptoms. Common symptoms include impaired cognition, irritability, depressed mood, and anxiety; all of which may reach severe levels which can lead to relapse.

Pain is a common reason patients seek medical care. Pain occurs due to both emotional and sensory inputs and has acute or chronic components. Acute pain has associations with the sympathetic nervous system and physical findings that include an elevated heart rate, respiratory rate, and blood pressure. Pupillary dilation and diaphoresis may also be evident. Chronic pain usually does not involve sympathetic responses and may be associated with depression, fatigue, and loss of appetite and libido.

Acute Pain:Typically occurs in response to acute tissue injury, results from activation of peripheral pain receptors and specific A-delta and C sensory nerve fibers (nociceptors).
Chronic Pain:Typically occurs in response to ongoing tissue injury and is thought to be caused by persistent activation of A-delta and C sensory fibers. The severity of tissue injury does not generally predict the severity of the pain. Chronic pain may result from damage or dysfunction of the peripheral or central nervous system causing neuropathic pain.
Nociceptive Pain:Nociceptive pain can be somatic or visceral.  Somatic pain receptor stimulation produces dull or sharp local pain. Burning is uncommon unless the skin or subcutaneous issues are involved.  Locations of these receptors include the skin, fascia, subcutaneous tissues, periosteum, endosteum, and joint capsules.  Visceral pain receptors result in pain due to an injury of organ capsules and connective tissue. Pain can be localized or sharp. Visceral pain as a result of obstruction of a hollow organ is poorly localized, deep, and cramping, and can possibly cause referred pain to other sites. 
Pain Modulation and Transmission of Pain

Pain fibers enter the spinal canal and the spinal cord at the dorsal root ganglia and then synapse in the dorsal horn. Fibers cross over and go up the lateral columns to the thalamus, followed by the cerebral cortex.

Repeat stimulus from a chronic painful condition may sensitize neurons in the dorsal horn of the spinal cord. As a result, a smaller peripheral stimulus may cause pain. Peripheral nerves and nerves at other levels of the CNS may become sensitized, producing long-term synaptic changes in cortical receptive fields that exaggerate pain perception.

When tissue is injured, substances are released causing an inflammatory cascade which can sensitize peripheral nociceptors. These include chemical messengers such as serotonin, bradykinin, epinephrine, calcitonin gene-related protein, substance P, neurokinin A, and prostaglandin E2.

Pain signals are modulated at multiple points in both ascending and descending pathways by several neurochemical mediators, including endorphins such as enkephalin, and monoamines such as norepinephrine and serotonin. These mediators are thought to increase, sustain, shorten, or reduce the perception of and response to pain. They mediate the potential benefit of central nervous system active drugs such as antidepressants, anticonvulsants, opioids, antidepressants, and membrane stabilizing agents that interact with specific receptors and neurochemicals in the treatment of chronic pain. 

How each person processes a drug, including the rate of chemical absorption and what occurs to excrete and metabolize the compound once it has entered the body is highly variable among individuals. Further, it may change with the degree and years of use disorder.

Psychologic Factors Causing Pain

Psychogenic factors can modulate pain intensity. Emotion has a vital role in one’s perception of pain. Patients in chronic pain have a high degree of psychologic distress and often suffer from anxiety and depression. Patients with poorly explained pain may be incorrectly diagnosed with a psychiatric disorder rather than a legitimate underlying cause of the pain. This results in the lack of pain relief which exacerbates the cycle of anxiety and depression.

Acute and chronic pain may impair concentration, memory, and thought processes. Pain may be multifactorial. Often pain is due to both nociceptive components as well as neuropathic (due to nerve damage).

Psychologic factors may also affect pain. It affects how patients describe the pain and their response. The psychologic reaction to long-standing chronic pain interacts with central nervous system factors to induce changes in the perception of pain. Psychologic factors generate neural output that modulates neurotransmission along each of the pain pathways.

Controlled Substance Act

All providers should be familiar with the guidelines and laws for each scheduled drug, including the purpose of the drug and the risk of use disorder. In the United States, controlled substances are under strict regulation by both federal and state laws which guide their manufacture and distribution. Controlled substances have a high risk of resulting in an addiction and substance use disorder. The schedules range from I-V, where a drug from schedule I has the highest risk for addiction and substance use disorder, and a drug from schedule V has the lowest risk of resulting in addiction and substance use disorder.

In the United States, the Comprehensive Drug Abuse Prevention and Control Act was passed in 1970, which includes the Controlled Substance Act. The Controlled Substance Act covers drug classification and regulation, manufacturing, distribution, and exportation and sales. The Controlled Substance Act established five drug schedules and classified them to control their manufacture and distribution. Part of the regulation requires that providers who prescribe scheduled drugs and pharmacists that fill them to obtain a license from the Drug Enforcement Administration, which includes specific license numbers allowing controlled substance prescriptions to be tracked and linked to a particular provider or distributor.

Each of the five schedules has parameters based on their medical value, the risk of addiction, and ability to cause harm. The schedules range from schedule I (most potential for addiction and use disorder) to schedule V (least potential for addiction/use disorder).

Schedule I

Schedule I drugs possess the highest potential for use disorder and misuse. They do not have any medical use and are illicit or “street” drugs. Examples of schedule I drugs include heroin, methylenedioxymethamphetamine (MDMA), methaqualone, lysergic acid diethylamide (LSD), marijuana (cannabis), and 3,4 methylenedioxymethamphetamine (ecstasy). Marijuana is legal in some states; however, it is still classified as a schedule I drug at the federal level. Schedule I drugs have the highest potential for misuse and drug use disorder.

Schedule II

Schedule II drugs have a reduced potential for use disorders than schedule I drugs, but the potential still exists for misuse and use disorders. They are also high risk for both physical and psychological dependence. Examples of schedule II drugs include dextroamphetamine, fentanyl, hydromorphone, meperidine, methadone, methylphenidate, morphine, oxycodone, pentobarbital, and secobarbital. These drugs are typically prescribed to treat severe pain, anxiety, insomnia, and ADHD. Schedule II drugs have the tightest regulations when compared to other prescriptions. They previously had to be prescribed only via paper prescription, but now are permitted to be electronically transmitted. (Electronic Prescribing of Controlled Substances or EPCS). No refills are allowed on schedule II drugs. 

Schedule III

Schedule III drugs have a lower potential for misuse that schedule I and II drugs. Drugs in schedule III category may cause physical dependence, but they are more likely to lead to psychological dependence. Schedule III drugs are often used for pain control, anesthesia, and appetite suppression. Examples of schedule III drugs include anabolic steroids, codeine, benzamphetamines, buprenorphine, ketamine, and phendimetrazine. Schedule III drugs can be prescribed over the phone, with a paper prescription, or by electronic prescribing of controlled substances. Drugs in this category are allowed to be refilled a maximum of five times within a six-month period.

Schedule IV

Schedule IV drugs have an even lower potential for misuse than schedules I, II, or III. Examples of schedule IV drugs include alprazolam, carisoprodol, clonazepam, clorazepate, diazepam, lorazepam, midazolam, and temazepam. Drugs in this class may be used for anxiety and pain control as long as the provider believes the drugs are medically necessary and would be beneficial to the patient. These drugs have a limited risk of physical or psychological dependence and can be prescribed verbally over the phone, with a paper prescription, or by the electronic prescribing of controlled substances. Refills are permitted to a maximum of five times within a 6-month period.

Schedule V

Schedule V drugs are the least likely of the controlled substances to be misused. Examples include cough medicines with codeine, antidiarrheal medications that contain atropine/diphenoxylate, pregabalin, and ezogabine. These drugs result in limited physical or psychological dependence. Despite their low potential for abuse, schedule V drugs still need to be managed appropriately and administered with care. For instance, cough syrup that contains codeine must have less than 200 mg per 100 mL. This schedule allows for partial prescription fills, however when a drug is partially filled it is treated in the same manner and with the same rules as a full refill of a drug; a refill cannot occur more than six months after the original date of issue.

Drug Use Disorder, Abuse, and Misuse

Use disorder of prescription drugs has become a common problem. Opioid use disorder and opioid addiction remain at epidemic levels in the US and worldwide. Three million US citizens and 16 million individuals worldwide have had or currently suffer from opioid use disorder.

Those afflicted may not fit the profile of one who is addicted to street drugs. They are often people with jobs and chronic pain syndromes.  For multiple reasons, they may self-medicate for pain control while maintaining their lifestyles. Since societal perception on using prescription drugs is that it is normal, access may be easier and safer than obtaining illicit drugs.

Often, patients are not appropriately educated on the addictive potential of controlled a substance such as a benzodiazepine or opioid. They are not aware of the danger if prescription renewals are easily accessible, especially if they see more than one prescriber. Of those patients receiving treatment in an emergency department, some are actually seeking additional medication to supplement their current consumption of opioids. Studies have found of those patients prescribed opioids in an emergency setting, 5-10% are already consuming opioid medications from other prescribers. Many states have made this problem less prevalent by instituting statewide reporting of controlled substances prescriptions.

Drug use disorder differs from abuse and misuse of a drug. Misuse of a controlled substance refers to the use of a prescribed drug in a way that was not intended. It usually involves taking the drug in a harmful or detrimental way that results in personal, professional, or social problems. Drug misuse may be deliberate or accidental. Examples of misuse include taking too much of a drug, using an incorrect dose route, or using prescription drugs written for another person. The drugs taken may be illicit street or stolen drugs or obtained by a legal prescription.

Controlled substances include both prescription drugs and illicit drugs with no recognized medical value. Both have the potential to be abused or misused. While schedule I drug use is illegal, prescription drugs found in schedules II-V are also commonly abused and misused, and their misuse is a challenging problem that has increased over the last several years.

The Centers for Disease Control and Prevention has declared prescription drug abuse is a problem of epidemic proportions and believes that without checks and balances on the prescription and distribution of controlled substances, the potential for abuse and misuse will continue to increase.

Diversion

Some individuals use controlled substances in ways for which they were not originally intended. Rather than pain control, they may be used to stay awake, induce sleep, or get “high.” Some prescription drugs will sell on the street for as much as $50 a tablet. Diversion is when a patient sells their drugs as a method of earning money. Drugs may also be sold to buy food, pay expenses, or purchase more potent street drugs. Worse, in some cases, healthcare providers may divert drugs from patients for the providers own personal use or sell them to someone else. Before the popularity of prescription drug diversion, the only method to obtain illicit drugs was to import them from other countries or manufacture them in private labs. Today, law enforcement agencies have the tremendous challenge of dealing with prescription drugs sold by diversion as well as illicit drugs imported or manufactured. In both instances, diversion through drug sales and usage result in increased criminal activity as well as dangerous overdoses and death. 

Signs and Symptoms of Drug Seeking and Diversion

A common method to evaluate whether a patient is taking, or misusing opioids is a random urine drug screen. Studies show that as high as 25% of patients prescribed opioids will randomly test negative. Patients discontinue opioid use due to remission of pain, side effects, lack of efficacy, and in some instances opportunities to sell their medications. Behaviors Suggesting Opioid Drug Use Disorder include:

  • Aggressive demand for more drugs
  • Forging prescriptions
  • Increased alcohol use and lack of control
  • Increasing dose without permission
  • Injecting or inhaling drugs prescribed for oral use
  • Obtaining drugs from illegitimate sources
  • Obtaining opioids from other providers
  • Prescription loss
  • Refusing to decrease pain medication dosage when stabilized
  • Requesting early refills
  • Requesting specific medications
  • Resisting medication change
  • Selling drugs
  • Sharing prescriptions
  • Stockpiling medications
  • Using illegal drugs 
Pill Shopping

A common practice among those that deliberately misuse controlled substances is to seek out multiple sources of drugs. They do this by seeing different health care providers, and often present with a different list of complaints that are fictitious and different for each provider. The patient may be able to obtain multiple prescriptions and then fill them at different pharmacies. Many states have enacted systems like medication reconciliation that allow providers to see all of the prescriptions written for each patient. Use of these systems is gradually curbing “pill shopping.” ⁸

Assessing for Opioid Use Disorder

The history and physical examination in patients with opioid use disorder varies depending on the duration and intensity of use. Patients who sporadically misuse small doses of opioids may have a completely normal physical exam and no clear assessment findings. Patients with chronic oral opioid use may have sedation if actively using the drug, along with miosis and a hyperactive response to pain. 

For providers, it may be difficult to distinguish legitimate pain from drug-seeking behaviors. Pain is often difficult to assess because patients may be impaired, or they may not be truthful when discussing substance abuse patterns. The astute provider should rely on a combination of taking an accurate history, physical, and observation-based assessment.

Signs of pain include:

Symptoms of pain include:

Pain can be evaluated by asking questions regarding:

Aggravating Factors:Does anything make it worse, such as movement or a position?
Associative Factors:Other relevant questions from a review of systems based on the patient complaint.
Character:A description of how the pain feels (dull, pinching, pounding, sharp shooting, throbbing, pounding, stinging, burning)?
Duration:For how long have you had the pain?  Is it episodic?
Onset:When did the pain start?
Progression:Has the pain gotten worse or better since it started?
Radiation:Does the pain move anywhere?
Relieving Factors:Does anything you do or not do make the pain better? What treatments have you tried?
Severity:What is the pain severity (1 to 10)?
Site:Where is the pain? Where does it hurt?
Evaluation of Pain

The clinicians must have a complete understanding of the patient’s primary disease and any issues in regard to the evaluation of proper use, potential side effects, and effectiveness of opioid use for chronic pain. Providers who suspect opioid use disorder should begin with a detailed history and physical exam. Often, patients with opioid use disorder also have medical conditions requiring opioid use. Examples of conditions that may require acute or chronic opioid analgesic use include:

Abdominal epilepsyAbdominal migrainesAchilles Tendon InjuriesAdhesive Capsulitis  
AdenomyosisAdhesionsAdnexal cystsBrachial Neuritis  
CancerCarpal Tunnel SyndromeCervical Disc DiseaseCervical Myofascial Pain  
Cervical SpondylosisCervical Sprain and StrainComplex Regional Pain SyndromesCervical stenosis
Chronic pelvic painChronic visceral painChronic fatigue syndrome  Colitis
DyspareuniaEndocervical polypsEndometriosisFibromyalgia
Gastrointestinal problemsHerniasIrritable bowel syndromeLateral epicondylitis  
Lumbar degenerative disk diseaseLumbar facet arthropathyLumbar spondylolysis  Mechanical back strain
Medical epicondylitisMononeuropathy and nerve entrapment  Morton neuromaMyofascial pain
Neoplasia of the spinal cordNeoplastic brachia plexopathy  Neoplastic lumbosacral plexopathyOsteoarthritis
OsteoporosisOvarian retention syndromePelvic floor pain syndrome  Piriformis syndrome
Radiation-induced brachial plexopathyRadiation-induced lumbosacral plexopathy  Rectus abdominis painRotator cuff disease
Pelvic varicositiesPlantar fasciitisReproductive system disorders  Spasticity
Substance abuseThoracic outlet syndromeTraumatic brachial plexopathy  Trochanteric bursitis
Uterine leiomyomasUrinary system disordersUrolithiasisVulvodynia 

Patients with opioid use disorder may initially withhold information, or be overtly dishonest and manipulative, depending on reasons for seeking medical attention. Along with the history and physical findings, diagnosis of opioid use disorder can be made by meeting two or more of the following eleven criteria in a year time period.

  • Increasing dose/tolerance
  • Wish to cut down on use
  • Excessive time spent to obtain or use the medication
  • Strong desire to use
  • Use interferes with obligations
  • Continued use despite life disruption
  • Use of opioid in physically hazardous situations
  • Reduction or elimination of important activities due to use
  • Continued use despite physical or psychological problems
  • Need for increased doses of the drug
  • Withdrawal when dose is decreased

As mentioned above, these patients are at risk for secondary effects of drug abuse. Patients dependent on heroin frequently have infectious complications. Therefore, many patients should have laboratory studies ordered and selected imaging depending on presenting symptoms. ¹⁰˒²

Treatment of Pain

Due to the risks of dependency with opioid use, the opioid prescription should include a treatment agreement or written informed consent. Treatment agreements should include notification of the following risks:

  • Drug interactions
  • Motor impairment
  • Physical dependence
  • Short and long-term risks/benefits
  • Side effects
  • Tolerance
  • Use disorder and misuse

Prescribing practices should be stated, including:

  • Frequency of refills
  • Policy regarding early refills
  • Procedure for lost or stolen medications

Opioid analgesics should be prescribed for a limited period, typically several days to 3-4 weeks. Patient education on the risks and benefits of opioid analgesic treatment should always be a feature of opioid prescribing. The goal of treatment should be defined at the outset, including establishing the estimated period for opioid therapy, expected side effects, expected pain improvement, and avoidance of using more medication than prescribed without prior discussion with the provider. The plan for treatment should include the medication selected, starting dosage, measures to track pain relief, and associated therapies such as occupational or physical therapy which can help decrease pain sensation.²

The initial patient dose of pain medication that is prescribed should always be started at the lowest dose possible. If necessary, the dose and frequency of a drug to achieve the desired effect may be increased. Dosing should be adjusted to achieve efficacy and tolerability. The patient should clearly understand the need for regular monitoring of progress and the need to frequently access the benefits and risks. The patient should be aware of complications such as constipation, fatigue, nausea, and risk of respiration depression. The patient should also be notified that only one prescriber should prescribe and monitor the opioid analgesic therapy. Further, patients should understand that all prescribers (for other ailments such as cardiology or nephrology) need to be aware of opioid dosing so that other agents that may interact and cause additional respiratory depression can be avoided.

When prescribing opioid drugs, prescribers must be aware of the need for patient monitoring, equianalgesic dosing and cross-tolerance. Prescribers need to consider the risks and benefits of short vs. long-acting/extended-release opioids. All prescribers must be aware of federal and state opioid prescribing regulations.

If a patient is found to have opioid use disorder, the provider should offer inpatient or outpatient opioid use disorder treatment. Also, patients presenting with opioid withdrawal will often require antiemetic/antidiarrheal therapy and intravenous fluid replacement. Medications for opioid use disorder, such as Buprenorphine can be prescribed for effective therapy in a medically supervised opioid withdrawal. Buprenorphine should be started in patients with mild-to-moderate withdrawal symptoms. Methadone can also control opioid withdrawal symptoms and complete opioid detoxification. ⁴

Opioid overdose should be promptly treated with naloxone to reverse the effects of the drug, especially if respiratory depression is present.  Adequate intravenous access allows the administration of fluids and repeat naloxone dosing when indicated. The intravenous dose of Narcan 0.4 to 0.8 mg may be used to reverse neurologic and cardiorespiratory symptoms.¹ Patients who have taken large doses of very potent opioids may require larger doses of Narcan and it can also be administered intranasally and intramuscularly if intravenous access cannot be obtained. All patients at risk for overdose should receive naloxone kits for home use. ⁹

Conclusion

A common concern of patients is how effectively we treat their pain. The provider must work collaboratively with the patient to assess and treat the pain appropriately and avoid opioid use disorder.  The therapy should always be started on the lowest dose possible, and then the dose and frequency can gradually be increased to achieve the desired effect. The prescriber should ensure that the patient clearly understands the need for regular monitoring of progress and for the need to frequently assess the benefits and risks of treatment. The patient should be aware of complications such as constipation, fatigue, nausea, and risk of respiratory depression. The patient should make sure that only one healthcare provider prescribes and monitors their opioid analgesic therapy. Further, patients should understand that all healthcare providers they see are aware of any current opioid analgesic to avoid polypharmacy and medication interaction with other prescriptions. This can help reduce the chance of medication-induced central nervous system or respiratory depression. The healthcare team must be aware of federal and state opioid analgesic prescribing and dispensing regulations. Due to the inherent risks of opioid use disorder, any opioid analgesic prescription of greater than a few days duration should include a treatment agreement or written informed consent. The agreement should also require the patient to have only a single licensed healthcare provider prescribe their opioid analgesic prescriptions. The patient should receive counsel to contact the healthcare team for problems and make in-person appointments for refills. The agreement should discuss monitoring, need for follow-up visits, storage, and disposal of opioid analgesics not used. The agreement should list possible reasons for the discontinuance of opioid analgesic therapy.

References
  1. Clinton, H. A., Hunter, A. A., Logan, S. B., & Lapidus, G. D. (2019). Evaluating opioid overdose using the national violent death reporting system, 2016. Drug and Alcohol Dependence, 194, 371-376. https://doi.org/10.1016/j.drugalcdep.2018.11.002
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