NEW ORLEANS – Patient visits involving prescription of opiates for chronic pain can be among the most cringe-producing encounters in primary care medicine.
These visits place physicians in the difficult position of determining whether a patient is lying or in chronic pain, said Dr. Barak Gaster, a general internist at the University of Washington, Seattle.
The goal is to help slow the arc of the pendulum of opiate prescribing. Fueled by recent reports of overdose deaths from opiates being greater than those from heroin and cocaine combined, the pendulum is rapidly swinging away from a period of overprescribing, which fed the nation’s huge prescription drug misuse problem, and is now headed back towards undertreatment of chronic pain.
"I think if we all get too freaked out by the [risk of] fatal overdoses and too frustrated by what a difficult area this is, more and more doctors will say, ‘I just don’t [prescribe opiates] anymore.’ And that would be a shame because there are definitely people who benefit from being on chronic opiates," he said at the annual meeting of the American College of Physicians.
A few practical tools make opiate prescribing safer and more efficient in a busy primary care practice, according to Dr. Gaster. Here are his recommendations for safer, more manageable opiate prescribing:
Establish a clear upper limit on dosing: An upper limit is, quite simply, the most important thing physicians can do to limit inappropriate opiate prescribing. The epidemiologic literature indicates that the risk of unintentional fatal overdose jumps at more than 120 milliequivalents of morphine per day, a value that "exceeds my comfort zone," Dr. Gaster said. But wherever the line is drawn – say, 60 or 80 milliequivalents per day – stay the course no matter what the patient says.
"What little research has been done in this area suggests that opiates have mild to moderate efficacy for chronic pain, that very low doses are about as likely to work as very high doses, and that in situations where you’re not achieving adequate pain control at lower doses the idea that you can just go to higher and higher doses is wrong and you’ll end up causing harm," he said.
The notion that dosing should continue to increase until pain control is achieved is appropriate for cancer pain, which is the setting where most physicians-in-training learned to use opiates, but it’s all wrong for noncancer chronic pain, he noted.
Have your patter down: Physicians need to have a pre-rehearsed response in mind for when they walk into the examination room and patients say that the maximum dose isn’t getting the job done. That ready-made response will keep the office visit moving briskly along. Here’s what Dr. Gaster suggested: "Honestly, I don’t believe that higher doses would be safe for you. This is the maximum dose that I feel comfortable prescribing in a safe way."
Make smart use of written care agreements: Many physicians try to list every possible aberrant behavior and transgression in the care agreement. That’s a mistake, Dr. Gaster said. The document ends up becoming a multipage contract, and nobody except lawyers read multipage contracts. Keep the agreement short.
"The main value of a care agreement is to quickly communicate what the rules of opiate prescribing are in your clinic. If you’ve effectively communicated those rules and patients are not able to follow them, that is when you have actionable information to identify those at high risk for prescription drug abuse," he explained. "If you’re confident that you’ve been clear, and yet the rules aren’t being followed, that’s when you can feel okay about saying, ‘This isn’t safe. It needs to stop.’ "
To be an effective communication tool, the care agreement needs to say that the medication cannot be refilled early, refills are done by clinic appointment only, and appointments for refills must be requested at least two business days in advance. Also, lost or stolen medications can’t be refilled.
"The number of lost or stolen opioid scripts, compared to the number of lost or stolen blood pressure medication scripts, is pretty impressive," he noted. "You have to be up front with people and say, ‘This bottle of pills is like cash and if you lose it I can’t replace it.’ "
The clear message must be that failure to follow these rules will result in discontinuation of opiates.
And don’t simply tuck the signed care agreement away in the patient’s file.
"Repeating what the rules of opiate prescribing are in your clinic at least two, three, or even four times on different occasions is absolutely essential, just so that you feel really confident that the patient got the message," Dr. Gaster continued.