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Six Things to Consider Before Prescribing an Opioid
March 29, 2018

Six Things to Consider Before Prescribing an Opioid

Caroline Carney, MD, MSc, FAPM, CPHQ
Breaking the cycle of prescription opioid abuse requires new thinking around pain management and alternative options for helping patients deal with chronic pain. Here are 6 things physicians should consider before prescribing an opioid.
More than 46 Americans die from prescription opioid overdoses every day, while the number of deaths from prescription opioids has more than quadrupled since 1999. Lack of expertise on how to measure and treat pain is a large factor driving the crisis. In addition, challenges in identifying those who are at risk for opioid abuse or who are already dependent on opioids adds further complexity.

Americans consume 80% of opioid painkillers produced worldwide. Yet the amount of pain reported hasn’t changed since in the past 2 decades, according to the CDC. For physicians, this points to the need to reconsider when to prescribe an opioid—if at all. Providers face intense pressures to adequately treat pain and may not know the data that supports nonopioid therapies. 

Breaking the cycle of prescription opioid abuse requires new thinking around pain management and alternative options for helping patients deal with chronic pain. The following are 6 things physicians should consider before prescribing an opioid.

1. Evaluate whether cognitive behavioral therapy could be the patient’s first defense against chronic pain

Cognitive behavioral therapy is a type of psychotherapy that helps patients better cope with challenges by identifying triggers to pain, behaviors and emotional responses, including chronic physical symptoms, life stresses, anxiety, and psychological trauma. Some cognitive behavioral therapy techniques seek to change patients’ behavioral patterns through relaxation techniques, role playing and learning to face one’s fears rather than avoiding them. Others focus on changing patients’ emotional mindset by encouraging patients to think about their problems in a different light.  

Today, digital and virtual solutions for cognitive behavioral therapy give patients access to counseling modules for a number of conditions, providing on-demand and flexible access to therapy via a computer or an app. Often, patients can access to cognitive behavioral therapy for free through the employee assistance programs offered through employers or insurers.

2. Determine whether the patient has an underlying condition that could contribute to the perception of pain

Recent studies indicate that for some conditions, depression and anxiety can heighten a patient’s perception of pain; so can stress and tension. That’s why effective treatment of chronic pain involves more than managing the patient’s physical symptoms—it also requires careful evaluation of the ways in which the patient’s mood, mental health, and outside stressors might be amplifying the patient’s response to those symptoms. Screening tools can help physicians determine whether patients have mental health conditions that have previously gone undiagnosed. In some instances, screening results might also point to an existing substance use disorder that has gone undetected.

3. Explore whether complementary therapies might provide long-term relief

Low-impact physical activities, such as yoga, walking, or swimming, have the potential to ease chronic pain without the use of pain medication. Yet complementary treatments, including physical therapy, are often underutilized in treating chronic pain. Research shows that physical activity not only reduces secondary muscle tension and improves stress tolerance, but also influences the perception of pain. Consider exploring options for activities and therapy that could help patients avoid pharmacological treatment and provide long-term relief.

Weight loss also may provide the relief patients seek and is a healthier alternative to pain medications. Even a five-pound weight loss can reduce pain levels for patients suffering from chronic conditions by improving the spatial distribution of pain, according to a 2017 University of Michigan study published in The Journal of Pain. Look for a medically led program that helps patients lose weight safely while monitoring their overall health.

4. Consult with a pain management coach

Some physicians, such as surgeons, feel pressure to prescribe opioids to treat pain, especially when quality programs rate providers in part by how well they manage pain—and scores may be linked closely to reimbursement. Pain management coaches can help physicians determine when opioids are truly needed and when alternative medications or approaches should be explored to help the patient find relief.

Pain management coaches use digital therapy and motivational interviewing to help patients manage their pain without turning to opioids. When patients are prescribed a short-term dose of opioids, pain management coaches also can be used to help transition patients off opioids by teaching patients techniques to manage their pain without turning to opioids.

5. If pain pills are determined to be the right treatment, consider whether a nonopioid medication is the best choice

For example, would prescription-level doses of ibuprofen or acetaminophen, combined with physical therapy, cognitive behavioral therapy or weight loss, have the potential to help the patient? Would interventional treatments, such as injections guided by interventional radiology to reach the precise site where pain emanates, be an option for relief? Is the core cause for pain being properly treated? If the patient has a condition such as rheumatoid arthritis or Crohn’s disease, could infusion of pain medication, delivered under a nurse’s supervision, be a viable alternative? There are many options for treatment that could—and should—be explored before prescribing an opioid.

Partner with pharmacists or other experts in medication management in determining which alternative medication options could be right for the patient before prescribing an opioid. Given the high risk of opioid addiction after just four to five days of use, it’s critical that physicians are absolutely certain that an opioid is the right choice for the patient before a prescription is written.  

6. Counsel the patient before prescribing

Much like using informed consent, patients need to know the risks and benefits of using opioids, including significant side effects like constipation and mental status changes. Teach patients about the expected trajectory of pain and how long-term use of opioids may be more harmful. Providers can use their state’s controlled substance prescription monitoring data to understand whether the patient is at high risk for addiction by understanding whether the patient receives narcotics or other risky medications from other providers. In cases where pain is expected to be short-term, limit the number of tablets prescribed, and provide step-down instructions for other forms of pain. 

Exploring Options for Patients’ Health

Opioids are meant to provide short-term relief from pain; they are not intended to be a long-term solution. By exploring alternatives to the use of opioids in managing patients’ pain, physicians not only will help prevent the continued spread of opioid addiction, but also will give patients the tools they need to live happier, healthier lives.

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