Prescribing Opioids: A Question of Balance

By P. Tennent Slack, M.D.

On considering the implications of a recent MedScape article, “The Opioid Crisis: Anatomy of a Doctor-Driven Epidemic,” it would seem that the attention that is focused on the issue of the prescription opioid overdose problem has finally reached critical mass. As physicians and prescribers, we find ourselves at the epicenter of a controversy that is fundamentally a practice-of-medicine question.

Unfortunately, the medical community at large has not approached the prescription opioid problem from a practice-of-medicine perspective, and we have consequently invited forces outside of medicine to have a growing influence over this arena. Most physicians would agree, however, that opioids play a vital role in the treatment of pain in a wide variety of settings and that physicians are best positioned to influence how and when an opioid should be used.

As many of you know, the Centers for Disease Control and Prevention (CDC) recently issued opioid prescribing guidelines that have garnered considerable attention. These kinds of guidelines are nothing new. Guidelines often contain finer points that don’t always achieve universal agreement, and the CDC’s recommendations are no exception.

As opposed to many other medical treatment scenarios, the book on opioid-based pain treatment is written not in black and white but in gray, which further promotes a lack of consensus. This ambiguity resides at the heart of the confusion and controversy surrounding how to rationally use this important tool in the pain-treatment toolbox.

As part of its ‘Think About It’ campaign, the Medical Association of Georgia Foundation has developed a Six-Point Opioid Prescribing Platform that captures the essence of discriminating opioid prescribing. This platform has been approved and endorsed by the Medical Association of Georgia (MAG), the Georgia Society of Interventional Pain Physicians (GSIPP) and the Georgia Society of Addiction Medicine (GSAM).

These organizations believe that these simple points can be useful in day-to-day treatment decisions across the spectrum of pain treatment, from acute to chronic, and can be used to promote more discriminating opioid prescribing. At the end of the day, however, the decision to deploy opioid therapy is a medical judgement, and as such there will always be unintended consequences. As physicians, the best we can do is to mitigate undesirable outcomes through discriminating prescribing.

The Six‐Point Opioid Prescribing Platform

1. How definable is the source of pain?

As is true with the treatment of any disease process, the risk-benefit assessment of a therapeutic intervention is influenced by our ability to define the disease. In cases where the source of pain is poorly defined, this should be considered when deciding whether or not to use opioid therapy. A poorly defined source of pain does NOT mean that opioid therapy shouldn’t be used.

2. Consider all treatment options.

The gamut of pain treatment options ranges from biofeedback techniques to surgery. Treatment options should clearly begin with the lowest risk treatments, which often involve the temporary cessation of pain-inducing activities, ice/heat, NSAIDs, etc. The decision to use opioid therapy should ALWAYS occur within a paradigm of risk-benefit assessment rather than a reflexive action.

3. SCREEN for risk of addiction/abuse.

There are a number of different screening questionnaire tools, some of which are quite extensive, others of which are very simple. As a practical matter, however, there are a handful of high-yield questions that should ALWAYS be asked when initiating opioid therapy: “Have you or a family member ever had a problem overusing pain pills that have been prescribed following an injury or painful procedure?” “Have you or a family member ever had a substance or alcohol abuse problem?”

4. If opioids are prescribed, target the LOWEST effective dose and the LOWEST number of pills per prescription.

An excellent way to do this is to simply ask the patient, “What is the lowest dose and least number of pills I can prescribe for you in one bottle?” This immediately assigns responsibility to the patient and gives the prescriber an insight into the patient’s understanding and expectations surrounding opioid therapy. Be aware of Georgia’s 911 Medical Amnesty Law, which allows you to prescribe or co‐prescribe naloxone (typically an intranasal delivery system) to a patient for use by non‐medical personnel for emergency opioid overdose rescue.

5. Educate the patient.

‐ Advise the patient of the risks/benefits of opioid therapy

‐ Advise the patient that sharing or using other people’s prescription medication is ILLEGAL

‐Advise the patient of proper prescription drug storage and disposal methods. (Note: All of the above are highlighted in the ‘Think About It’ patient pamphlets that can be obtained by calling 678.303.9282 or going to rxdrugabuse.org.)

6. Monitor the patient for opioid overuse/diversion. If opioid therapy is sustained, use Georgia’s Prescription Drug Monitoring Program (PDMP). Information on how to sign up for and use the PDMP is available at the Georgia Drugs and Narcotics Agency, http://gdna.georgia.gov/georgia-prescription-drug-monitoring-program or call 404.656.5100.