Help for the Front-Line Physician and Opioid Dependent Chronic Pain Patient
By Craig Uthe, MD
Many physicians are looking for direction and guidance for an evidence-based treatment model to address the challenging and complex needs of the opioid-dependent chronic pain patient. There is help; help for the patient and resources for the doctor.
First, patients are becoming more aware of the grave consequences of opioid misuse and abuse. Health campaigns have effectively warned the public that more Americans are dying of unintended opioid overdose on a daily basis than are dying in motor vehicle accidents. Thus, patients are increasingly visiting physician offices asking to be taken off pain medications. Personal awareness and desire to succeed is the first and most important step to recovery.
Third, the pendulum has swung away from the obligation for physicians to prescribe opioids to treat pain as a vital sign. The focus to “function over pain” is a new direction that is leading patients in a direction where success is more realistically achievable.
Fourth, guidelines, checklists and plans of action published and promoted by the CDC in early 2016 are very useful resources for health teams, physicians and patients that provide practical direction and guidance in developing treatment plans and boundaries. These four useful resources listed below are easily accessible and available for download and printing:
Useful one page checklist for prescribing opioids for chronic pain
Useful two page guideline for prescribing opioids for chronic pain
Reducing the Risks of Relief—The CDC Opioid-Prescribing Guideline, TR Frieden, N Engl J Med. 2016 Apr 21;374(16):1501-4. doi: 10.1056/NEJMp1515917. Epub 2016 Mar 15.
Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use, Jeffrey A. Gudin, MD, Postgrad Med. 2013 Jul; 125(4): 115–130. doi:10.3810/pgm.2013.07.2684
Complementing and highlighting some of the content in the resources above are some general points to remember:
1) Opioid overdose is life-threatening; opioid withdrawal is not life-threatening. If your patient is at a dangerous MME (milligrams of morphine equivalent) dosage, work to reduce the dosage to a non-lethal daily dosage.
2) In general, sole benzodiazepine overdose is not life-threatening; benzodiazepine withdrawal is life-threatening. If uncertain, it is generally safer to provide a patient an appropriate benzodiazepine dosage rather than deny the drug.
3) Avoid prescribing the combination of opioids and benzodiazepines. A patient concurrently taking this drug combination is at significantly greater risk for an unintended overdose death.
4) Emphasize the avoidance of alcohol consumption to the patient who is taking an opioid or benzodiazepine. Alcohol remains the most common abused substance in the U.S. and its consumption while on an opioid and/or a benzodiazepine increases the risk for unintended opioid overdose deaths.
Caring for and treating the opioid-dependent chronic pain patient is not easy. But then, how much of what is done in medicine is considered easy? Building mutual trust and respect between the physician and patient is of utmost value. Making him or her aware that the path of addressing and treating opioid dependence will be difficult but can be rewarding with high functioning and controlled pain. Inviting, encouraging and even challenging the patient into that journey with reassurance that you will provide support and guidance along the way is time-consuming and demanding for the physician. Assembling a team of support with necessary resources will help. More non-opioid pain treatment resources are becoming available. Waiting for the patient to get into a comprehensive, multi-disciplined pain clinic with easy access and availability is not likely to occur in the immediate future. Until then, the physician can follow these resources to help some patients out of this dangerous condition. Ultimately, the health care team can only help create a safe environment for the patient to most likely succeed. The rest is up to the patient. Let’s see if we have the resolve and discernment to help the patient out of risk and into a safe place.