New to Prescribing Opioids? What You Need to Know to Keep Your Patients Safe
For patients with chronic pain, opioid medications can offer an important treatment option. If you are a clinician who is new to prescribing opioids, there are several important resources and best practices that can help keep your patients safe and properly treated while receiving opioids.
Centers for Disease Control Guideline for Prescribing Opioids for Chronic Pain
In 2016, The Centers for Disease Control and Prevention issued a comprehensive Guideline for clinicians on the use of opioids for treatment of chronic, non-cancer pain. The Guideline is a significant document, some 49 pages long, which summarizes the clinical evidence for a set of 12 recommendations. The full Guideline and recommendations are available on the CDC website. In brief, the recommendations include:
- Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain.
- Treatment goals should be established and progress toward them reevaluated periodically.
- Risks and benefits should be discussed with the patient, and evaluated regularly during therapy.
- Treatment should begin with immediate-release, rather than extended-release or long-acting opioids.
- The lowest effective dosage should be used.
- Prescriptions should only be written for the expected duration of pain.
- Clinicians should evaluate benefits and harms within 1 to 4 weeks of beginning therapy, and then at least every 3 months.
- Before and during therapy, clinicians should evaluate risk factors for opioid-related harms, and incorporate risk mitigation strategies into the treatment plan.
- Clinicians should review state prescription drug monitoring program data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose.
- When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
- The combination of opioids and benzodiazepines should be avoided whenever possible.
- For patients with opioid use disorder, clinicians should offer or arrange follow-up treatment.
The Role of Urine Drug Testing
As noted in the CDC Guideline, urine drug testing has an important role to play in keeping your patients safe when receiving opioid medications. According to the 2018 Quest Health Trends Report, based on a comprehensive evaluation of over 3.9 million samples between 2011 and 2017, over half of all samples tested showed evidence of drug use inconsistent with the physician’s prescription. Urine drug monitoring provides objective data and insight into what drugs patients are actually taking – including information on illicit drug use and dangerous drug combinations, which state prescription drug monitoring program prescription data cannot provide. In this way, testing is an important complement to PDMP data, providing you with a more complete picture of your patients.
Quest Diagnostics offers a comprehensive set of tests for patients on chronic pain medications, providing information on prescribed drugs, non-prescribed drugs with potential for abuse, and illicit drugs.
The Importance of Patient Communication
At every step of the treatment process, it is vital to engage in frank, sympathetic conversation with your patients. As noted in the CDC Guideline, it is important to be realistic about the potential benefits of opioid therapy. They state, “While opioids can reduce pain during short-term use, there is no good evidence that opioids improve pain or function with long-term use, and that complete relief of pain is unlikely.” A full discussion of risks—to the family as well as the patient—is critical for making an informed decision. As part of developing the treatment plan, the clinician should ask patients about use of drugs and alcohol, in order to more fully understand the risks the patient may be experiencing. More conversation is needed as treatment continues. If a drug test result indicates an inconsistent result—either absence of a prescribed drug or presence of a non-prescribed or illicit one—it is the clinician’s responsibility to discuss the results with the patient before or in conjunction with a change in prescription.