The Opioid Dilemma

Recent studies indicate a dramatic increase in accidental deaths associated with the use of prescription opioids and an increasing average daily morphine equivalent dose (MED) of the most potent opioids since 19991-3. Between 1999–2006, people aged 35–54 years had higher poisoning death rates involving opioid analgesics than those in any other age group4.
In response to the increasing morbidity and mortality associated with the increasing use of opioids, the Centers for Disease Control and Prevention5 has
1 The AMDG consists of the medical directors from these WA State Agencies: Corrections, Social and Health Services (Medicaid), Labor and Industries, and the Health Care Authority

released several recommendations for how health care providers can help. The recommendations include:
 

• Use opioid medications for acute or chronic pain only after determining that alternative therapies do not deliver adequate pain relief. The lowest effective dose of opioids should be used
• In addition to behavioral screening and use of patient agreements, consider random, periodic, targeted urine testing for opioids and other drugs for any patient less than 65 years old with noncancer pain who has been treated with opioids for more than six week
• If a patient’s dosage has increased to 120 mg MED per day or more without substantial improvement in function and pain, seek a consult from a pain specialist.
  
• Do not prescribe long-acting or controlled- release opioids (e.g., OxyContin®, fentanyl patches, and methadone) for acute pain.

Medication Treatment

Choose  drugs  based  on  presumed  pain  type  and  the  patient’s  comorbidities. 

-  NSAIDs and/or acetaminophen can be effective for chronic musculoskeletal or arthritis pain. In older adults, NSAIDs and COX-2 inhibitors should be used rarely and with caution, monitoring for GI and renal toxicity, hypertension, and heart failure. [1D]*  

-  Adjuvant medications Tricyclics (TCAs), SNRIs (duloxetine) and second generation anticonvulsant medications are effective for specific neuropathic pain states. [1A]* For centralized pain/fibromyalgia, TCAs, SNRIs, gabapentin and pregabalin are effective. [1A]*  

-  Opioid analgesics can be safe and effective for some patients with chronic non-terminal pain [I1B]*, but require careful patient selection, titration and monitoring. Scheduled, long-acting opioids, (morphine ER, or methadone, buprenorphine) are preferred for continuous treatment [ID]*. OxyContin has a higher risk for misuse or diversion. Avoid long-term, daily treatment with short-acting opioids and opioid combinations (e.g., Vicodin, Norco, Percocet). For  “as  needed”  (PRN)  dosing,  prescribe  small  amounts  expecting  monthly  (not  daily)  use. 

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Interventional Spine Procedures

 

 

Opioid-Induced Hyperalgesia

A Comprehensive Review of Opioid-Induced Hyperalgesia (Pain Physician 2011; 14:145-161)

Understanding Opioid Pain Medications

 If opioid analgesics have been used or are being considered, dependence and addiction risk should be assessed through careful personal and family history, review of outside records and assessment of illicit or prescription medication misuse. Check your State’s prescription monitoring program (PMP) and perform a urine screen by combination of enzyme immunolinked assay (EIA) and gas chromatography/mass spectroscopy (GCMS) prior to prescribing and at least yearly for patients given chronic opioid therapy. [ID]* 

If initiating opioid therapy:
Assess risk for addiction (see Table 3)
Present opioids as a tool to help reach functional improvement goals; be clear that opioids will be continued only if they
contribute to functional improvement or maintenance
Establish prescribing practices: one prescriber/one pharmacy, no after-hours refills, no early refills without appointment,
compliance with adjuvant therapies, no Emergency Department visits for pain medications, random urine drug screens, required follow-up  at  scheduled  intervals.    See  model  “Controlled  Substance  Treatment  Agreement”  in  Appendix  C.

 



For patients being considered for, or already receiving, chronic daily opioid therapy: check comprehensive drug screen = EIA + GCMS (at UM = DRUG COMP = Drug6 (i.e. EIA) + GCMS) and search State prescription monitoring programs (PMP) for opioid prescriptions (e.g., MAPS search in Michigan [https://sso.state.mi.us], OARRS in Ohio [www.ohiopmp.gov]).