Clinical Education Center
Opioid Therapy - Strategies for a Safer Approach
With prescription drug abuse a significant public health concern, there is growing debate about the relative risks and benefits of prescribing opioids for chronic pain.1, 2 While acknowledging the scale of the problem, Dr Steven Passik, Professor of Psychiatry and Anesthesiology, Vanderbilt University Medical Center, warns against a misguided move away from opioid therapy and a stigmatization of patients treated with opioids. In his view, the most important issue is not whether opioids should be prescribed for selected patients with chronic pain, but how to ensure physicians manage opioid therapy appropriately.
Managing the Risks
“The issues confronting us today are a consequence of the fact that we were very successful in encouraging physicians to use more opioids and created a paradigm shift in pain management” observes Dr Passik. “The downside is that this occurred without putting in place strategies to deal with the negative impact of opioids on high risk people.” With no alternative approaches likely to completely supplant the use of opioids on the horizon the key question for Dr Passik is whether we can we prescribe opioids safely.
A safe approach is founded on risk assessment. Once a physician has determined that opioids are required in a given patient, the first step is to assess the patient’s risk level and decide how to tailor opioid therapy for that individual patient. Dr Passik stresses the importance of recognizing how complex this assessment is: “It requires staffing, adequate time, a particular practice structure and a willingness to take a methodical approach with those patients who are medium to high risk.”
Dr Passik notes the misapplication of theories, whose relevance to human pain experience is not entirely clear, that are used to justify a reluctance to prescribe opioids. One example is the increased concern about opioid-induced hyperalgesia, defined as a state of nociceptive sensitization caused by exposure to opioids3. “Hyperalgesia is something that’s easy to demonstrate in animals. It’s not so obvious or easy to demonstrate in humans,” says Dr. Passik. “There are numerous reasons why patients may not feel well on their opioids or believe their opioids aren’t working so well for them but the relationship between this commonplace observation and hyperalgesia are is unclear. I think we need to be intellectually and ethically honest so as not to come up with theories that are over-extended and unproven.”
The solution to such concerns is to pursue appropriate opioid therapy rather than avoid it altogether. “This means you need to know how to manage side-effects. It also means ensuring patients are optimized on their opioids. Prescribing a dose below optimum levels due to concerns of addiction or hyperalgesia is not justified.”
A Blueprint for Opioid Therapy
Underlining the need for an “appropriate approach” to opioid therapy, Dr Passik identifies four principles:
- Doctors understand and identify risks
- Doctors employ a toolbox of interventions to help manage risk across the spectrum
- The need to provide adequate support for a sub-set of patients who require psychiatric support, physical therapy, extra visits and additional monitoring.
- Pain practitioners have sufficient time to integrate all available information into patient management
The Intervention Toolbox
Interventions for physicians should include screening tools to help determine a person’s risk level, a prescription monitoring system that alerts doctors in real time, and urine screening.
Urine screening is essential since it has been established that physicians are unable to judge by clinical evaluation alone which patients are likely or unlikely to be adherent4, 5.
Routine testing should be included as part of any pain management program. “I say to my patients all the time, you don’t go to Weight Watchers without expecting to step on the scale and to my mind urine screening is the scale for pain management with opioid therapy.” Dr. Passik emphasizes this is not a matter of trying to “catch people”, but a way to support people undergoing treatment and to help them self-monitor.
Opioid Risk Evaluation and Mitigation Strategies (REMS)
Looking ahead, the proposed REMS for opioids6 is one of the most eagerly anticipated changes in the field.
Overdose is one area of opioid complication in which Dr Passik sees REMS having a significant impact: “You can teach doctors about drug titration and you can have the doctors in turn teach their patients about how drugs have been titrated, switched or rotated so they are less vulnerable to overdose.”
While strongly endorsing the need for more education on pain management, Dr. Passik is concerned REMS is too limited in scope, due to its single agency approach: “Educating the providers is important but those providers only have contact with a small proportion of those using or abusing opioids in the community. It’s hard to see that REMS is going to have a significant impact on prescription drug abuse if large segments of the problem are not in the purview of the FDA” requiring a multi-agency approach.
To have a dramatic impact on abuse and diversion Dr Passik believes a broader public health approach is needed. This would educate patients about drug storage and not sharing drugs and would include “giveback days” organized by law enforcement to prevent opioids remaining in a patient’s home when they’re no longer being used. He would also like to see more Recovery Schools7 - institutions attended by teenagers recovering from prescription drug abuse, which provide monitoring and recovery support within the school setting.
It is hoped that a focus on the safe, effective way to manage opioid therapy will minimize its risks, while ensuring optimum treatment for chronic pain patients.
- White House Drug Policy Director Highlights Growing Public Health Toll of the "Prescription Drug Abuse Epidemic; Office of National Drug Control Policy; Thursday, January 6, 2011; http://www.whitehousedrugpolicy.gov/news/press11/010611.html
Opioids for Chronic Pain; Deborah Grady, MD, MPH; Seth Berkowitz, MD; Mitchell H. Katz, MD; Arch Intern Med. Published online June 13, 2011. doi:10.1001/archinternmed.2011.213
Opioid-induced Hyperalgesia in Humans: Molecular Mechanisms and Clinical ConsiderationsChu, Larry F. MD, MS (BCHM), MS (Epidemiology); Angst, Martin S. MD; Clark, David MD, PhD*; Clinical Journal of Pain: July/August 2008 - Volume 24 - Issue 6 - pp 479-496
Universal precautions in pain medicine: a rational approach to the treatment of chronic pain; Gourlay DL, Heit HA, Almahrezi A; Pain Med. 2005 Mar Apr;6(2):107-12.
Michna, Edward MD, JD*; Jamison, Robert N. PhD* et al; Urine Toxicology Screening Among Chronic Pain Patients on Opioid Therapy: Frequency and Predictability of Abnormal Findings;Clinical Journal of Pain:February 2007 - Volume 23 - Issue 2 - pp 173-179