Should I Prescribe Another Opioid for This Patient?

Carolyn Buppert, MSN, JD


December 07, 2015

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A clinician who performs minor surgical procedures is in a quandary about whether to prescribe an opioid for postprocedure pain to patients who are already taking opioids.

Carolyn Buppert, MSN, JD
Healthcare attorney

A nurse practitioner asks about management of acute postoperative pain, but this dilemma is common to all clinicians who perform minor surgical procedures.

As part of my practice, I perform a minor surgical procedure. The procedure usually calls for a controlled analgesic for a few days afterwards. Sometimes, the patient having the procedure is already taking large doses of one or more powerful pain medications for chronic, noncancer pain. If that is the case, should I prescribe the usual postprocedure pain medication? In one case, a patient was already taking powerful analgesics—more powerful than I normally prescribe—so I declined to prescribe yet more pain medication. The patient complained to his insurer, who then wrote me a letter saying that I was deficient in treating pain. Must I, should I, or even can I prescribe pain medication for a patient who already is being treated for pain?

Your reluctance to pile more pain medication onto a patient already being treated with controlled drugs is wise. If I received a deficiency letter from an insurer for making the decision you made, I would probably respond, in writing, describing my reasoning for declining to provide pain medication and asking the insurer to respond with their recommendations for how to handle this decision in the future.

Predicting what is safe for each patient is a complex calculation and requires consideration of unique variables. You are an expert at your procedure but not necessarily an expert on treating pain. You can become an expert on treating pain, if you like, but otherwise you will need help in figuring out what to do with patients who are already being treated for pain. The safest course would be to contact the patient's prescribing clinician. Decide whether your additional prescription is necessary and appropriate and whether it will compromise the primary provider's treatment plan. Furthermore, you will need to know whether the patient's primary prescriber and the patient have agreed that the primary prescriber will be the sole prescriber of pain medication. It is common (and standard of care) for a clinician who treats chronic, noncancer pain with opioids to require that each patient agree not to accept pain medication from any other provider. If the patient knows that and still wants a prescription from you, it may indicate that the patient is not willing to comply with his other prescriber's requirements. That may be grounds for the primary prescriber to terminate his relationship with the patient.

Another consideration is whether this patient should be treated as being naive to opioids or whether to take tolerance into account. And you will need to consider that your procedure calls for treating acute pain, and the regimen the patient is on prior to your procedure likely is for chronic pain. So you will need to decide whether the patient's current regimen is going to cover the acute pain.

I recommend that you do some research to see what other clinicians in your line of practice do. Perhaps controlled drugs aren't necessary for this particular procedure. It makes sense to come up with a practice policy or, at minimum, have your own policy about how you will handle this decision in the future. You want to treat pain responsibly; but, on the other hand, you don't want to be manipulated by patients or cause a problem for their pain management clinicians.

Here is a resource about pain management that clinicians might find useful: "Acute Pain Assessment and Opioid Prescribing Protocol." (Editor's Note: You may also find Medscape's Pain Management Center useful.)


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