Chronic, non-cancer pain > 3 months, is a common complaint of patients seeing physicians.






Opioid therapy is most commonly used to treat such pain, however, its efficacy and safety in treating non-cancer chronic pain is debated. A burden of adverse consequences due to opioid misuse or overuse is escalating at an alarming rate globally.

At this juncture, measures have to be taken to mitigate the problem of misuse of opioid during chronic pain management. The AAFP Editorial 2017 (American Association of Family Physicians) quotes

“ we must take the lead in reducing opioid misuse and overdose before outside entities mandate practice strategies that may not be patient centered.”

Mu-opioid receptors are concentrated in the periaqueductal gray, thalamus, cingulate cortex, and insula, which regulate the pain perception and pain-induced emotional responses. These receptors are the sites where the opioids bind and exert their analgesic effects. Opioids lower the pain threshold and even a mild pain becomes intolerant and the patient urges for the drug for relief.

Here, we review certain guidelines to be followed by the physician while prescribing opioids for pain management.

 

Selection and dosage of opioid

• Upon the commencement of opioid treatment, physician should prescribe the lowest possible effective dosage and should increase if needed by the smallest practical quantity.
• If the dosage of opioid increases to 50MME or more per day, physician should implement additional precautions and increase the follow ups.
• Physicians should avoid increasing the dosage of opioid to 90MME per day or should carefully decide based on the benefits of increased dosage.

When high dosages of opioid are prescribed, physicians should consider offering naloxone.
 

Mitigation Strategies

• Prescription Drug Monitoring Program (PDMP) data should be used to review the patient’s history of controlled substance prescriptions that helps to avoid opioid overdose.
• Initial urine drug testing should be performed for commonly prescribed opioids and illicit drugs before the initiation of medication for chronic pain management.
• For chronic pain treatment with opioids, physicians should prescribe immediate release opioids instead of extended-release or late acting (ER/LA) opioids.
• ER/LA opioids should not be prescribed for intermittent use or with combination of immediate release opioids.
• Methadone should be avoided as first choice of ER/LA. If prescribed, physician should be familiar with methadone’s risk profile and the patient should be monitored carefully.
• Patient should be advised about the possible common side effects like dry mouth, drowsiness, vomiting, confusion and withdrawal symptoms when stopping opioids.
• Patient and family members should be informed in advance about the chances of serious adverse effects including fatal respiratory depression and lifelong opioid dependency.
  
  
  The strategies improve the communication between the physician and patient making it easier for the physician to understand, treat and simultaneously reduce the risks associated. This can help both physicians and patients to ensure the safe and effective use of opioids.
   

  
  
  
  
  References

  1. Deborah Dowell, MD, MPH; TamaraM. Haegerich, PhD et al., CDC Guideline for Prescribing Opioids for Chronic Pain-United States, 2016. Clinical Review and Education. JAMA. 2016; 315(15):1624-1645.

  2. Nora D. Volkow, M.D., and A. Thomas McLellan, Ph.D. Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies. Review article. The New England Journal of Medicine. 2016. N Engl J Med 2016;374:1253-63.

  3. David T. O’Gurek, MD, FAAFP and Robert Rich Jr., MD, FAAFP. Chronic Pain Management and Opioid Misuse: Guidance for Family Physicians. Am Fam Physician. 2017;95(7):420.

  4. Laxmaiah Manchikanti, MD, Adam M. Kaye, PharmD et al., Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician, 2017; 20:S3-S92

  5. American Medical Association. The American Medical Association Task Force to Reduce Prescription Opioid Abuse. https://www.ama-assn.org/sites/default/files/media-browser/public/washington/opioid-overview-ama-only.pdf. Accessed on 30 June 2017