"Health care professionals should not abruptly discontinue opioids in a patient who is physically dependent," announced the Food and Drug Administration, after receiving a series of concerning patient reports. Finding a balance between optimal pain control and safety when prescribing opioids for chronic non-cancer pain (CNCP) is no easy feat. However, the constantly evolving opioid guidelines, the fear of overprescribing opioids, and regulatory scrutiny can sometimes make it challenging for CNCP patients to access healthcare. Someone who knows this only too well is Karen Widener, from Nashville, Tennessee.
Opioids are Widener’s only option to manage CNCP. She was diagnosed with a mitochondrial degenerative disease and now relies on Oxycodone as her sole pain relief medication. "Sometimes, it's not so bad. Other times, it's like somebody is sticking a knife between my joints and twisting it," she shares.
Widener often faces stigma at the doctor's office. "They think I'm here to get more pain pills. I'm not. I want to know what's wrong—what's causing this pain. Once they know you're on opioids, they assume that's what you're there for."
Widener is not alone. Patients treated with opioids for CNCP commonly experience discrimination when accessing healthcare. Chronic pain is a debilitating condition affecting an estimated 50 million Americans, and opioids are sometimes the only solution to effectively treat CNCP. How can this be better managed?
You have evaluated a CNCP patients’ pain severity, the nature of their pain, and its impact on their day-to-day functioning. Where can you go from here?
When clinically appropriate, start with non-opioid analgesics.
Review FDA-approved labeling and weigh up risks and benefits before initiating any pharmacological therapy.
Prescribe non-opioid analgesics (Acetaminophen and NSAIDs) and non-pharmacological therapy (behavioral, physical, and/or occupational therapy) as the first line of treatment, when clinically appropriate.
Use the lowest dose of NSAIDs for the required duration.
Use caution, particularly in patients with cardiovascular comorbidities, chronic renal failure, or previous gastrointestinal bleeding.
Additional drugs/adjuvants, like antidepressants, anticonvulsants, corticosteroids, and anxiolytics, can help alleviate pain.
Patient education is critical when prescribing opioids.
Centers for Disease Control (CDC) guidelines recommend opioids for CNCP management when expected benefits (i.e., pain relief and improved functioning) outweigh risks. However, no tool can perfectly predict potential risks, such as opioid-related harm or opioid use disorder. Thus, the decision-making process for individual patients remains challenging.
Having open and thoughtful communication with your patients before prescribing opioids can help keep adverse events at bay. It can ensure that your patients fully understand the expected effects of taking opioids and may strengthen your professional relationship with them.
Some patients may be hesitant to take opioids, being aware of the associated dangers but not the potential therapeutic benefit. By involving patients in the decision-making process and jointly determining treatment goals, you can help address any fears or concerns they may have. It will likely improve both treatment adherence and patient satisfaction. The objective is that each patient will understand the expected and normal responses to opioids and what warrants a phone call to the doctor's office.
A few things you could discuss before prescribing opioids:
Treatment goals, expectations, and patient responsibility to mitigate opioid treatment risks.
An 'exit strategy' whereby opioid treatment is unsuccessful.
The roles of regular toxicology screenings and prescription drug monitoring programs.
Use of Naloxone.
Behaviors incompatible with CNCP opioid therapy, like getting prescriptions from other clinicians or losing medications.
Your response to these behaviors.
Things to keep in mind when prescribing opioids.
Start with immediate-release opioids instead of long-acting opioids. (The starting dose for long-acting opioids is often higher and may result in adverse effects or misuse.)
Start with the lowest dose and shortest duration of opioids for pain relief.
Prescribe adjuvants (antidepressants, anticonvulsants, corticosteroids, anxiolytics) when necessary.
Consider behavioral, physical, and occupational therapy in addition to opioid treatment.
Set up regular follow-ups and perform periodic assessments.
Improving care and support with patient follow-up.
Regular follow-up plays a crucial role in supporting your patients and building trust. Follow-ups provide an opportunity to answer your patients' questions, identify misunderstandings, and adjust treatment dosage. You can also utilize follow-up appointments to identify early signs and symptoms of opioid misuse or overdose in an effort to prevent substance dependency.
As a physician, you can help reduce the stigma attached to CNCP. If your patient shows signs of an opioid use disorder or opioid overdose risk, dismissing them from your practice might adversely affect their health and safety or cause them to feel abandoned.
Discontinuing opioids or tapering them abruptly can exacerbate pain and cause acute withdrawal or psychological distress. Instead, collaborating with your patient and making smaller dose reductions will increase the likelihood of a successful taper.
As the guidelines for CNCP management continuously evolve, you can stay updated on the latest opioid prescription guidelines by visiting CDC's website. The CDC also offers free training with case studies to help you better support your patients and make evidence-based treatment decisions.
References
U.S. Food & Drug Administration. FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. 2019. Available from: https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes.
Dassieu L, Heino A, Develay E et al. “They think you’re trying to get the drug”: Qualitative investigation of chronic pain patients’ health care experiences during the opioid overdose epidemic in Canada. Can J Pain. 2021;5(1):66-80.
U.S. Department of Health and Human Services. Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. 2019. Available from: https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf.
Horan K. Antioch woman said opioid treatment for chronic pain causes stigma. NewsChannel5 Nashville. 2022 May 12.
Dahlhamer, J, Lucas J, Zelaya C et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. Morb. Mortal. Wkly. Rep. 2018;67(36):1001–1006.
Dowell D, Haegerich TM, Chou. R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(RR-1):1–49.
Ducharme J, Moore S. Opioid Use Disorder Assessment Tools and Drug Screening. Mo Med. 2019; 116(4): 318–324.
Centers for Disease Control and Prevention. Module 3: Communicating with Patients. 2020. Available from: https://www.cdc.gov/opioids/providers/training/communicating.html.
Moore SK, Guarino H, Acosta MC et al. Patients as collaborators: using focus groups and feedback sessions to develop an interactive, web-based self-management intervention for chronic pain. Pain Med. 2013;14(11):1730-40.
Center for Substance Abuse Treatment. Patient education and treatment agreements. 2012. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92049/.
U.S. Food & Drug Administration. FDA recommends health care professionals discuss naloxone with all patients when prescribing opioid pain relievers or medicines to treat opioid use disorder. 2020. Available from: https://www.fda.gov/drugs/drug-safety-and-availability/fda-recommends-health-care-professionals-discuss-naloxone-all-patients-when-prescribing-opioid-pain.
Centers for Disease Control and Prevention. Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain. 2018. Available from: Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain.
Centers for Disease Control and Prevention. Updated Draft CDC Guideline for Prescribing Opioids Overview of Public Engagement Work. 2022. Available from: https://www.regulations.gov/document/CDC-2022-0024-0005.
Centers for Disease Control and Prevention. Pocket Guide: Tapering opioids for chronic pain. 2019. Available from: https://www.cdc.gov/drugoverdose/pdf/Clinical_Pocket_Guide_Tapering-a.pdf.
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