Neil Osterweil

May 04, 2015

BOSTON — For patients with chronic noncancer pain, even when opioids are taken as prescribed, there is ample evidence of dose-dependent risk, according to one addiction expert speaking here at American College of Physicians Internal Medicine 2015.

In fact, 80% of current heroin users switched to heroin when prescription opioids became too expensive or too difficult to procure, said Molly Feely, MD, from the Mayo Clinic in Rochester, Minnesota.

"For 80% of current heroin users, prescription opioids were the gateway drug," she said.

When considering writing a prescription for opioids, clinicians should use a formal risk-assessment tool, have a plan in place for high-risk patients, and "document, document, document," said Dr Feely.

And opioids should be a last resort, not the go-to choice, when a patient presents with chronic pain, she added.

The US Centers for Disease Control and Prevention called the abuse of prescription opioids the "worst drug overdose epidemic in history," and placed opioid overdosing on its list of top public health challenges, Dr Feely reported.

For 80% of current heroin users, prescription opioids were the gateway drug.

According to American Society of International Pain Physicians guidelines, only 40% of opioid overdoses are related to aberrant use or abuse (Pain Physician. 2012;15[3 Suppl]:S1-S65). The remaining 60% are caused by patients taking either high-dose opioids (40%) or low-dose opioids (29%) as prescribed and in accordance with prescription guidelines. High-dose opioids are considered to be more than 100 mg of an oral morphine equivalent per day, or combined prescription of an opioid and a sedative agent.

Risk Factors for Misuse

The abuse or misuse of prescription opioids is most common in patients with a personal or family history of alcohol or drug misuse or a comorbid psychiatric condition, such as depression, schizophrenia, attention deficit disorder, obsessive compulsive disorder, or bipolar disorder.

For the safety of the patient and the practice, it is incumbent on clinicians to carefully assess patients for risk for drug abuse or diversion, to have a detailed discussion on the pros and cons of opioid use, and to follow patients to ensure the safety and appropriateness of ongoing opioid therapy, Dr Feely said.

She recommends a free risk-assessment tool that can be used either online or downloaded and printed out before the prescription of opioids. The tool also aids in documentation.

If a patient is considered to be at high risk, the clinician should provide a referral to a subspecialty pain clinic, and explain the rationale for the referral to the patient.

Clinicians should also query a prescription-monitoring database to rule out the possibility that the patient is a "doctor shopper" who seeks out multiple prescriptions from different providers to feed a drug habit.

Dr Feely said she strongly recommends getting a baseline urine test before prescribing "to make sure what is supposed to be there, is there," and "that nothing that is not supposed to be there, isn't there."

Commercial urine drug tests vary in their ability to screen for certain drugs, however, so it is important for clinicians to know the metabolites of various drugs. And urine drug tests are subject to both false-positive and false-negative results, and adulteration can alter results.

Treatment agreements, or "drug contracts," should be thought of as informed-consent documents, Dr Feely said.

Treatment Agreements

Such agreements allow clinicians to document discussions on the risk for opioid misuse and nonopioid alternative therapies, the expectations of both parties, and required procedures, such as follow-up, assessment, and prescription renewals.

Adherence monitoring allows clinicians to assess whether the medication is working as intended and whether the adverse effects are acceptable. The assessment can reassure clinicians that patients are not misusing the drug, and periodic urine testing can provide clues as to whether the patient is taking the drug as prescribed or illegally diverting it to someone else.

At every visit, clinicians should query a prescription-monitoring database, assess the patient for aberrant behavior and functional status, and consider adverse-effect management, such as the use of laxatives for drug-induced constipation.

At random visits, a urine drug test and a pill count should be conducted, Dr Feely advised.

The management of patients who are on chronic opioids is challenging, said Jane Neuman, MD, an internist in private practice in Oakhurst, New Jersey.

"Our local pain management people don't want to prescribe chronic opioids," she told Medscape Medical News. "As a matter of fact, some of them send letters to us letting us know that they will no longer be prescribing chronic opioids and dismissing the patients back into our care — sort of passing the buck back to us."

In fact, the pain clinics in her area refuse to take insurance, she said, and a consultation costs the patient $350 to $450.

"Primary care is really in a bind in this area," Dr Neuman said.

Dr Feely and Dr Neuman have disclosed no relevant financial relationships.

American College of Physicians (ACP) Internal Medicine 2015. Presented May 1, 2015.


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