In a discussion of opioid use disorder (OUD), often taken for granted is why many patients begin using opioids in the first place: to stop pain. While we can discuss the merits of various treatment methods once patients have already developed an OUD, (and we do), increasingly physicians are forced to rethink when is it appropriate to prescribe opioid painkillers in the first place. Here are some talking points that have surfaced:
When it may NOT be appropriate
- The patient is experiencing acute pain.*
- The patient is experiencing chronic pain, and nonpharmacologic therapy and nonopioid pharmacologic therapy have not yet been attempted.
- The patient is concurrently using benzodiazepines such as Valium or Xanax.
- Risks have not been discussed.
- A patient’s prescription drug use history has not been reviewed in the state’s PDMP.
- Achievable pain and function goals have not been discussed.
- An end date has not been established.
*In some cases it may be appropriate to prescribe opioids for acute pain. If opioids are needed for acute pain, the advice is don’t over-prescribe. “Start low and go slow.” Do not write a prescription for more than a few days’ worth of pills (the CDC recommends 3-7). Further, do not prescribe extended-release and long-acting (ER/LA) opioids for acute pain.
Guiding principles
For patients that are experiencing chronic pain and have not experienced the relief they sought from other therapy methods, it may be appropriate to use opioids. However, they should be made well aware of the potential risks, and appropriate steps should be taken. It is unfortunate that the rule of thumb seems to have been treat the pain, do not worry about the addiction.
The “start low and go slow” philosophy may be a good start. Unfortunately, an end date was rarely discussed in the past. Now physicians are having more and more restrictions placed on them when prescribing a controlled substance even if justified for the patient.
The use of opioids to treat pain should not be considered a permanent solution from the start if possible. From the beginning, the prescriber and patient need to determine achievable goals (such as improved pain or function) and evaluate whether these have been achieved in subsequent visits. The duration of use or end date should be determined from the start.
All of these steps should be revisited each time the prescriber and patient opt to continue the use of opioids or increase dosage. Too many medication cabinets are stocked with prescribed controlled substances never taken, or never completed, only to get in the wrong hands of an adolescent or adult that should not have access.
When it is appropriate
- The patient is experiencing chronic pain (or acute pain and safety measures specific to acute pain have been taken).
- Nonpharmalogical and nonopioid solutions have failed.
- The patient’s prescription drug monitoring program (PDMP) history has been reviewed and they did not have a prior history of opioid use disorder.
- The patient is not using benzodiazepines (prescribers should avoid prescribing benzodiazepines and opioids concurrently wherever possible).
- The prescriber and patient have established achievable goals.
- The dosage is at the lowest possible amount.
- The duration of use has been established.
- The patient understands the risks of using opioid medications and has decided it is worth it anyway.
A positive takeaway: opioids should only be prescribed when the prescriber and patient have both decided the benefits will outweigh the risks. Education about the risks is very important and managing expectations.
For more information
If you would like to download either of the documents Guideline for Prescribing Opioids for Chronic Pain or Checklist for prescribing opioids for chronic pain, fill out this form.
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