CE: Appropriate Use of Opioids in Managing Chronic Pain : AJN The American Journal of Nursing | AJN, American Journal of Nursing: July 2016 | Denenberg, Risa MSN, RN, ARNP; Curtiss, Carol P. MSN, RN-BC
This is a very long and complete article on all aspects of opioid prescribing, so even my annotations run to almost 3,000 words.
Perhaps because it is written by nurses, who seem to be more realistic about pain, this is a much more balanced article than the usual alarmist anti-opioid propaganda.
Abstract: The authors discuss current best practices for prescribing opioids for chronic pain, emphasizing patient assessment and essential patient teaching points regarding safe medication use, storage, and disposal.
Over the past two decades, the use of opioids to manage chronic pain has increased substantially, primarily in response to the recognized functional, emotional, and financial burden associated with chronic pain.
Within this same period, unintentional death related to prescription opioids has been identified as a public health crisis, owing in part to such factors as insufficient professional training and medication overprescription, misuse, and diversion.
Chronic pain, also known as persistent pain, is any pain that continues beyond the period over which healing would normally occur (generally three to six months) and affects a person’s function or quality of life
an estimated 126 million U.S. adults have varying degrees of pain, ranging in persistence from “some days” to “every day” and in intensity from “a little” to “a lot.”2 Nearly 40 million of them experience the highest levels of pain intensity on “most days” or “every day.
In addition to the tremendous physical and emotional suffering chronic pain causes, it is also a significant public health problem that places an enormous financial burden on patients, their families, their employers, and health care systems.
While chronic pain can be alleviated through effective and compassionate treatment, it is rarely eliminated entirely.
Although prescription opioids have been associated with misuse, abuse, diversion, and unintentional death, this is in part owing to such factors as insufficient provider education and professional training
UNDERSTANDING CHRONIC PAIN
Acute pain alerts the patient to risk of tissue damage or injury. Chronic pain may start with an acute pain episode that persists long beyond the time of expected healing, or it may occur spontaneously, as is the case with fibromyalgia and various types of neuropathy
While guideline recommendations for using opioids to treat chronic pain differ in some respects, most agree on general assessment and management principles, noting that opioids remain a necessary option for managing chronic pain in selected patients and that they should be used not as monotherapy, but as part of a comprehensive multimodal plan of care that includes nonpharmacologic interventions and nonopioid medications as first-line therapy (see General Guidelines for Assessing and Managing Chronic Pain 5-13)
ASSESSING PATIENTS WITH CHRONIC PAIN
Initial and follow-up assessments are often a nursing responsibility. In addition to performing a complete physical examination and taking a thorough medical, psychosocial, and mental health history, the initial assessment of patients with chronic pain should include detailed questions about the following:
- pain location, quality, and intensity
- pain relief provided by all treatment interventions, both pharmacologic and nonpharmacologic
- effects of pain on the patient
- history of substance use disorders
- current and past functional abilities
- adverse effects of current treatments
- ability to perform activities of daily living, such as driving, working, going to school, performing housework, exercising, walking long distances, and climbing stairs
- psychiatric history
- quality of sleep, mood, and energy
Improved function and quality of life is the focus of follow-up visits. At every subsequent visit throughout treatment, patients with chronic pain should be questioned about
- any changes in pain level, location, or quality.
- any changes in medications.
- adherence to the management plan.
- adverse effects of opioids, particularly constipation.
- personal health.
- mood, sleep, and functional status.
- adverse health behaviors.
When patients report unrelieved pain, the possibility of a new or progressive problem should be considered and fully evaluated.
POTENTIAL ADVERSE EFFECTS OF OPIOIDS
Opioid-induced constipation is nearly universal and does not diminish with time. For most patients, management requires regular use of a stimulant or osmotic laxative as well as a stool softener.
is an adaptation to a drug that manifests in withdrawal symptoms upon the drug’s abrupt cessation or rapid dose reduction.
Physical dependence is an expected effect of opioid therapy and also occurs with many other psychoactive drugs, such as antidepressants and benzodiazepines
Tolerance to sedation, nausea and vomiting, euphoria, and anxiolytic effects of opioids develops rapidly.21 Tolerance develops more slowly to the analgesic effects of opioids, but when it occurs, it results in less analgesic efficacy
Any person taking opioids for several weeks or longer may experience symptoms of withdrawal (also called opioid abstinence syndrome) if the opioid dosage is rapidly decreased or if opioids are abruptly stopped
Symptoms of withdrawal are treated by resuming opioid therapy at a lower dose and providing a less drastic tapering schedule, or with an α-blocking agent, such as clonidine (Catapres and others)
The prevalence and underlying mechanisms of opioid-induced hyperalgesia are largely unknown. It is suspected when increases in opioid doses are paradoxically accompanied by an increase in pain or by the pain becoming more diffuse and less manageable.
As a patient ages, the most likely case for increased opioid need is increased pain, yet this is never considered by most doctors.
All opioids can cause respiratory depression and thus present a potential risk of unintentional overdose and death due to respiratory failure.
This is also the case for other sedating drugs, not just opioids:
sedating drugs, such as benzodiazepines, carisoprodol (Soma), zolpidem (Ambien and others), butalbital (found in some combination headache medications, including Fiorinal), gabapentin (Neurontin and others), pregabalin (Lyrica), hydroxyzine (Vistaril and others), promethazine (Phenadoz and others), and alcohol.
Methadone (Dolophine and others) interacts with a number of other drugs
Phenytoin (Dilantin and others), carbamazepine (Tegretol and others), rifampin (Rifadin), erythromycin (Eryc and others), and several antiviral agents increase methadone metabolism, thereby decreasing circulating drug levels and, potentially, efficacy, and possibly bringing on symptoms of withdrawal.
Antifungal drugs and selective serotonin reuptake inhibitors or tricyclic antidepressants may increase methadone levels, causing adverse events
Tramadol (Ultram, ConZip), a partial opioid agonist, also has norepinephrine and serotonergic properties. In combination with other serotonergic drugs, tramadol may precipitate the serious adverse effect of serotonin syndrome
MANAGING RISK AND PROMOTING ADHERENCE
Initial opioid risk assessment
Current recommendations and U.S. Food and Drug Administration (FDA) opioid labeling suggest that, for chronic pain, opioid therapy should be administered only to patients whose pain is moderate to severe and unmanageable without it.
This states that, without opioids, patients’ lives would be unmanageable. Yet, this is exactly what the CDC recommends.
Opioid risk screening tools, such as the Opioid Risk Tool (ORT), may be helpful in determining the type and intensity of monitoring the patient requires and the patient’s need for referral to additional supportive services. The ORT is a simple, validated, five-question survey that may be used to stratify patients into categories of low, moderate, and high risk before starting therapy (see Figure 2)
Several guidelines recommend the use of opioid agreements when opioids are considered for patients with chronic pain
These “agreements” are completely one-sided, leaving the patient unprotected and doctor mistakes, and are coerced since the patient will only be treated for their intractable pain if they sign. See The Tyranny of Pain Mgmt Contracts.
Both the prescriber and patient review and sign the agreement, which serves as an educational tool, a written reminder of mutual expectations, and a way to build patient and provider trust. Sample agreements may be found at: http://www.lni.wa.gov/Forms/pdf/F252-095-000.pdf and http://www.aafp.org/fpm/2001/1100/fpm20011100p47-rt1.pdf.
Random urine drug testing is used to determine whether patients are taking prescribed medications as directed and not illicit or prescription drugs that have not been prescribed
Initial screening is usually accomplished with a urine dipstick point-of-care test called an immunoassay. Patients are not usually observed or monitored while giving specimens in primary care settings. Drug screening should be seen as a routine test and a normal part of care for all patients taking opioids
Both false-positive and false-negative results are common with immunoassay testing. It is inappropriate to draw conclusions or confront patients about nonadherence based on immunoassay results alone
Yet, such a “failed” drug test is often cause for immediate dismissal from the practice without any chance for appeal by the patient. Doctors have no patience with any patient that had a failed drug test, whether it was actually valid or not, and there is no legal way to correct this injustice.
Providers must know how to correctly interpret the results. Communication with the testing laboratory is essential.
This is very, very rarely the case, even though these drug test are difficult to interpret correctly. See Patients “Fired” for Misinterpreted Urine Drug Tests, Urine Drug Test Often Gives False Results.
When a confirmatory test shows unexpected results, the patient should be seen in person to discuss the results and the possible reasons for the surprise findings. A positive, supportive approach that keeps the patient engaged in care is most helpful.
Pain management clinics are not trying to be “helpful”. They are only trying to keep the suspicions of the DEA at bay.
If the confirmatory test is positive for illicit drugs, the provider may choose to increase supervision and support for the patient to continue to use opioids or decide that the patient should taper off of opioids safely and rely on other strategies for pain management.
In reality, such patients are summarily rejected and receive no further care or contact from their pain management doctor. If this were any other drug, it would be considered unsafe and unethical to discharge a patient who is physically dependent on medication, since it forces them into health complications of withdrawals and lack of relief. It seems to me, this policy is to blame for sending patients to the streets to find drugs.
A pill count may reveal that a patient is taking more than has been prescribed because of increasing pain, running out early, and then “toughing it out” until the next prescription
This concern is apparently not shared by doctors, who are eager to “throw out” any patients who aren’t fully compliant for fear the DEA might find something to criticize.
Prescription drug monitoring programs
(PDMPs) are electronic databases through which providers licensed by the U.S. Drug Enforcement Administration (DEA) have access to information on when, where, and by whom prescriptions are dispensed for their patients.
the Prescription Monitoring Information Exchange (PMIX) provides a platform through which PDMPs may exchange data across state borders, giving clinicians an even broader look at patients’ prescription-filling histories,
Medication safety, storage, and disposal.
Patients receiving controlled medications such as opioids are responsible for keeping their medications secure at all times—safely stored in a concealed location or kept in a locked safe.
“Saving medications for later” also increases the risk of misuse and intentional or accidental ingestion by another person.
This is a shortsighted policy that encourages people to keep taking their opioids until gone, when they might otherwise take less instead of saving them to avoid another expensive doctor visit.
instruct patients not to crush tablets or capsules, but to mix medicines with an unpalatable substance such as kitty litter or used coffee grounds, place the mixture in a sealed plastic bag, and put it in the household trash.
To avoid water supply contamination, the U.S. Environmental Protection Agency has cautioned against flushing medications down a sink or toilet, but the FDA continues to recommend the flushing of certain medications, including fentanyl (Duragesic, Ionsys) and buprenorphine (Butrans) transdermal patches, which may contain a potentially lethal dose of medication even after use
The FDA is thus encouraging dangerous environmental damage, demonstrating another shortsighted policy around opioids.
SELECTING THE RIGHT OPIOID
Several opioids are commonly used to manage chronic pain (see Table 1).
Oral opioids may be short acting, with an onset of 45 to 60 minutes and a duration of three to six hours; or long acting, with a duration ranging from eight hours to seven days, depending on the product.
When combination products containing an opioid and acetaminophen, aspirin, or ibuprofen are prescribed, it is important to recognize and educate patients on the safe daily and long-term dose limits of the nonopioid component of the medication
There are known dangers to using these non-opioid drugs (even as directed), yet they are recommended over opioids, which are only dangerous if abused.
If a patient has had prior opioid treatment, morphine equivalency ratios may be considered (see Table 2), though actual conversion from one opioid to another requires a number of clinical considerations
Methadone dosing is unique and dose dependent. For example, 10 to 20 mg of methadone is considered the equivalent of 40 to 80 mg of morphine, while 30 to 40 mg of methadone is considered the equivalent of 240 to 320 mg of morphine. The ratio increases to 10:1 or more for methadone doses of 60 mg and higher
These equivalencies are not based on analgesic efficacy, but rather on the very long and unpredictable half-life of methadone that results in accumulation and adverse effects.
Buprenorphine displaces full mu-opioid receptor agonists, such as morphine (MS Contin and others), hydromorphone (Dilaudid, Exalgo), and oxycodone (OxyContin and others), causing acute withdrawal symptoms and increased pain
PATIENTS REQUIRING SPECIAL CONSIDERATION
Persistent pain is common and undertreated in patients 65 and older, leading in many cases to adverse outcomes such as impaired function, sleep, quality of life, and mobility (with the attendant risk of falls)
Nonsteroidal antiinflammatory drugs are often contraindicated or used with caution in this age group.
While older patients may benefit from judicious use of long-term opioid therapy,6 metabolic changes that occur with aging may slow drug metabolism and excretion, potentially leading to higher than expected serum drug levels.
Patients with compromised renal and hepatic function
Evaluate renal and hepatic function to determine safe dosages and dosing intervals
Patients with significant liver dysfunction should avoid products containing acetaminophen
Certain opioids, such as morphine and codeine, should be avoided in the treatment of patients with renal dysfunction, as they have active and potentially toxic metabolites that tend to accumulate in the presence of impaired renal clearance
the safest opioid options are those that are not excreted renally: transdermal buprenorphine, methadone, fentanyl, and sufentanil (Sufenta)
Effective birth control is essential when opioid therapy is considered in a woman of childbearing age. It is critical to refer women who discover a pregnancy while using opioid therapy to a high-risk obstetric program
Patients with sleep disorders or obstructive sleep apnea
Patients with symptoms of obstructive sleep apnea who are using opioid therapy should be referred for appropriate sleep evaluation.
The STOP-Bang questionnaire, which is a validated screening tool for identifying obstructive sleep apnea in surgical patients, may facilitate initial assessment. The questionnaire focuses on eight correlates of obstructive sleep apnea: loud snoring, tiredness, observed apneas, high blood pressure, body mass index, age, neck circumference, and gender. (For a copy of the questionnaire, go to http://www.stopbang.ca/osa/screening.php.)
Patients with depressed mood or anxiety
Chronic pain may adversely affect mood; conversely, depressed or anxious mood can increase pain perception. Identifying and treating depression and anxiety are part of a comprehensive pain management plan
The Patient Health Questionnaire-9, available at http://www.phqscreeners.com/sites/g/files/g10016261/f/201412/PHQ-9_English.pdf is a validated, self-administered nine-item tool commonly used to assess patients for depressed mood
The Generalized Anxiety Disorder 7-Item scale, available at http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf, is used to monitor the effect of anxiety on chronic pain.
Patients with adverse health behaviors should be offered nonjudgmental support, educational materials, and referrals to specialists to support behavioral change.
LEGAL AND PRACTICAL CHALLENGES TO PRESCRIBING OPIOIDS
In an attempt to reduce abuse and diversion, recent federal and state laws have increased restrictions regarding opioid prescribing practic
However, for patients at low risk for opioid misuse, and who are on a stable opioid dosage, a “fill date” can be entered in the directions to the pharmacist. In this way, a provider may choose to issue up to three separate prescriptions (that is, prescribe a 90-day supply) during one visit.
Few public or professional resources are available in most communities to support patients with chronic pain and their pain management providers
Ineffective and conflicting regulations present challenges to optimal and safe opioid use. Payer policies, preferred drug formularies, lack of reimbursement for such integrative therapies as acupuncture or massage, and poor coordination of education for health care professionals contribute to the challenges of prescribing opioids to manage chronic pain
Insurance coverage that limits the number of pills allowed in total, per month, or per prescription undermines provider decision making and patient care.
Burdensome prior authorization requirements by insurers create time-consuming hurdles to prescribing specific medications, including some opioids, anticonvulsants, and anesthetic patches for pain. Clinicians lose precious time in paperwork while patients wait, often in pain, for authorization.
Managing chronic pain is hard work and time consuming for both patients and clinicians. It’s common for both to become discouraged. This can cause patients to become angry or demanding and clinicians to minimize or dismiss the reports of pain from patients who need care. Lack of professional, patient, family, and community education perpetuates common myths and misperceptions about chronic pain and opioid use as part of pain management.
Both unrelieved chronic pain and misuse or abuse of opioids can reduce a patient’s quality of life
If pain management is a moral imperative, as the Institute of Medicine (now the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine) has asserted,1 then nurses have a responsibility to take the lead in directing safe and effective pain management practices.
The outline topic links below will take you to sections of the original full article.
- UNDERSTANDING CHRONIC PAIN
- ASSESSING PATIENTS WITH CHRONIC PAIN
- POTENTIAL ADVERSE EFFECTS OF OPIOIDS
- DRUG–DRUG INTERACTIONS
- MANAGING RISK AND PROMOTING ADHERENCE
- SELECTING THE RIGHT OPIOID
- PATIENTS REQUIRING SPECIAL CONSIDERATION
- LEGAL AND PRACTICAL CHALLENGES TO PRESCRIBING OPI…