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Practical Approaches

Practical Approaches to Opioid Prescribing

Universal precautions in opioid prescribing for chronic pain are recommended. As yet, there is no empiric evidence of their effectiveness in reducing the abuse of prescription opioids or the outcomes related to the abuse, misuse, or diversion of prescription opioids.8

Chronic pain is a serious public health issue.1 Patients with chronic pain, clinicians, payers, employers, and the government are confronted with these two major interrelated issues:1

  • Poor understanding and often inappropriate treatment of pain, including prescription therapy
  • Misuse, abuse, and diversion of opioid medications intended to treat pain

These challenges must be addressed in parallel to ensure that concerns about abuse and misuse of opioids do not preclude clinically appropriate opioid therapy for patients who need it.2,3

Given the well-documented problem of misuse, abuse, and diversion of prescription opioids, health care providers should do more to help encourage appropriate use.13 From a clinical perspective, appropriate use of opioid therapy for patients with chronic pain may be thought of in the framework shown here:

  • First, prescribe opioids only when clinically appropriate.4-9 Current FDA guidance is to prescribe extended-release and long-acting opioids only for patients with pain severe enough to require daily, around-the-clock, long-term treatment, and for whom alternative treatment options are inadequate.14 Treatment guidelines do not recommend opioids as first-line therapy for noncancer chronic pain.15
  • Second, when prescribing opioids for chronic pain, apply universal precautions—a set of uniform practices for prescribers that may help address misuse, abuse, and diversion.4-7,9-11

Although no single intervention will solve the complex problem of prescription opioid abuse, by taking these steps, you as a health care provider may be able to make a real difference.

Follow these links to find out more about clinically appropriate treatment selection and the application of universal precautions. To review these concepts within the context of a clinical setting, explore the accompanying case studies.

References

  1. Institute of Medicine of the National Academies. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011. PMID: 22553896
  2. US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research (CDER). Abuse-deterrent opioids; evaluation and labeling. Available at: https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformat.... Published April 2015. Accessed November 6, 2017.
  3. Volkow ND, McLellan TA. Curtailing diversion and abuse of opioid analgesics without jeopardizing pain treatment. JAMA. 2011;305(13):1346-1347. PMID: 21467287
  4. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer painc. J Pain. 2009;10(2):113-130. PMID: 19187889
  5. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Version 2.0. Washington, DC: US Dept of Veterans Affairs, US Dept of Defense; 2010. http://www.va.gov/PAINMANAGEMENT/docs/CPG_opioidtherapy_summary.pdf. Accessed November 6, 2017.
  6. Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An Educational Aid to Improve Care and Safety With Opioid Therapy. 2010 Update. Olympia, WA: Washington State Agency Medical Directors Group; 2010. http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf. Accessed November 6, 2017.
  7. Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2—guidance. Pain Physician. 2012;15(3 suppl):S67-S116. PMID: 22786449
  8. Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Salt Lake City, UT: Utah Dept of Health; 2009. http://www.dopl.utah.gov/licensing/forms/OpioidGuidlines.pdf. Accessed November 6, 2017.
  9. Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc. 2009;84(7):593-601. PMID: 19567713.
  10. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112. PMID: 15773874.
  11. Webster LR, Fine PG. Approaches to improve pain relief while minimizing opioid abuse liability. J Pain. 2010;11(7):602-611. PMID: 20444651.
  12. Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy RK. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10(2):131-146. PMID: 19187890.
  13. Centers for Disease Control and Prevention. Primary Care and Public Health Initiative. Prescription Drug Abuse and Overdose: Public Health Perspective. October 24, 2012. https://www.seattle.gov/documents/departments/cityAttorney/opioidLitigation/FN40%20PrescriptionDrugAbuseandOverdose-10-24-12.pdf. Accessed November 29, 2017.
  14. US Food and Drug Administration. New safety measures announced for extended-release and long-acting opioids: ER/LA opioid analgesic class labeling changes and postmarket requirements [letter to ER/LA opioid application holders]. September 10, 2013. http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM367697.pdf. Accessed November 6, 2017.
  15. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.