When You Decide to Prescribe Opioids

With the initiation of opioid therapy for acute pain there should be an understanding between the provider and the patient that opioids will be stopped within a 2 week window.  If pain extends beyond the 2 week window, consideration for a pain referral should be undertaken.

Long-term opioid therapy should be initiated with treatment goals in mind from the beginning.  Realistic goals should be set and based upon a diagnosis.  Nonopioid therapy must be optimized.  Clear risk benefit needs to be established with the patient prior to initiation of opioid therapy.  Every time a prescription is written PMP must be checked.  If there are multiple providers here, or there are overlapping narcotic prescriptions this must be discussed with the patient at the time of initiation of therapy.  Urine drug screens must be utilized prior to initiation of opioid therapy, and then some metric established for compliance or aberrancy over the course of therapy.  Keeping in mind the benefits of long-term opioid therapy are controversial.  Understanding risk factors prior to initiation is vital as well.  Things such as history of illegal drug use, substance abuse disorder, mental health issues, or concurrent benzodiazepine utilization puts the patient at increased risk.  Establishing these parameters from the outset with the patient is crucial in order to frame minimum CDC recommendations when it comes to opioid prescription therapy.  Patient's need to be fully completely aware that 1 single provider should be responsible for prescribing their opioids.

Higher dosages of opioids are associated with a higher risk of overdose and death.  However, higher dosages have not been shown to reduce pain over the long term.  In a recent study in the Journal of Spine a study showed virtually no difference in patient's perception of pain control with conservative opioid prescription writing and liberal opioid prescription writing.  The only difference was significantly increased risk of long-term opioid therapy in the liberal opioid group.  Keep in mind dosages at or above 50 morphine equivalence today increase risk of overdose by 2 X.  A national sample of Veterans Health Association patients had demonstrated patients who died of opioid overdose were prescribed an average of 98 morphine equivalents per day .  Other studies have shown average of 48 morphine equivalents per day was associated with death.  Any patient on regular doses in excess of 50 morphine equivalence a day should be in a formal pain clinic which is a highly monitored environment.