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Managing Chronic Pain Patients and Opioid Drugs


Treating chronic pain patients in primary-care practices can involve some extra work, but done wisely, the benefit to the majority of patients far outweighs the potential for abuse.

Prescription drug abuse in the United States is growing at an alarming rate, especially among young adults. During the period 2008 to 2011, nearly 28 percent of adults ages 18-25 used psychotherapeutic drugs for nonmedical purposes, according to the "National Survey on Drug Use and Health for Ages 12 and Older."

Prescribing opioid medications for patients who experience legitimate, chronic pain can be risky for both physician and patient. Yet, physicians can and should prescribe opioid medication for chronic pain patients, said Daniel P. Alford, program director for the Addiction Medicine Fellowship at Boston University School of Medicine, during a recent AMA webinar on "Assessing for Risk, Benefit and Harm when Prescribing Opioids for Chronic Pain."

He went on to say that while the potential for addiction and drug diverting is significant (89 percent and 75 percent respectively), "providers can be, and want to be, trained to prescribe opioids for chronic pain - safely and competently."

So, how should physicians approach their management of chronic pain patients?  Alford recommends adopting universal precautions when prescribing opioid medication: using patient agreements (that contain informed consent); assessing patients for drug abuse/ misuse; monitoring patient well-being through face-to-face visits; and setting up a program to monitor patients for adherence, addiction, and diversion - which includes pill counts and blood and urine testing.

Diana Douglas, vice president of risk management and patient safety, with California-based Cooperative of American Physicians, Inc., advises physicians to set in place policies and procedures for their staff members to assist in managing and facilitating treatment for chronic pain patients.

 "First and foremost, [physicians] really should have a policy regarding the number of prescription refills provided before requiring the patient to return back to the office," Douglas recently told Physicians Practice. "Keep in mind, too, that the physician's staff is really in the forefront of the line, as to who the patient first meets…"

She also recommends that physicians develop a drug contract that informs patients "that they agree to submit to urine and/or blood [testing] at any time. That it is requested to be tested for alcohol or drugs."

When asked about other ways physicians can protect themselves and their patients against potential prescription drug abuse, Douglas strongly recommends that informed consent be part of every drug contract. She says physicians should sit down with each patient and review the use of "opiate analgesic for the treatment of chronic pain … which includes the side effects and risks" at both the beginning of treatment and periodically throughout the patient's course of treatment.

While most patient visits are brief and physician time is at a premium, it is vitally important for physicians to be on the lookout for red flags that might indicate patient drug abuse or diversion.

Douglas says that lost or "stolen" prescriptions and medications are often indicative of illicit activity. She also advises that physicians should not give in to unreasonable requests from demanding patients, or those patients who have socially influential positions, like celebrities. She adds that physicians should review the patient's medication list at each visit, and periodically request a patient activity report, through a program like the Controlled Substance Utilization Review and Evaluation System (CURES).

Douglas says, "If a doctor suspects that a patient may be obtaining prescription medications from another source, they can obtain this particular report to get an idea of exactly what medications have been provided to their patients by other practitioners."

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