Practice tips for opioid prescribing

Prescription opioids remain a profound clinical challenge, and we as prescribing practitioners have a significant amount of control over this epidemic. About 14,000 people die from prescription opioid overdoses each year in the United States. Our good intentions to alleviate patient suffering are inextricably bound to the reality of potential iatrogenic harm.

As the corpus of knowledge around best practices for safe prescribing has evolved, hopefully we are evolving our practice for our own patients. But for patients whom we inherit from other practitioners or for those who have been in our practice for years on high doses of opioid analgesics, we need to become comfortable telling them, "Things are different now." In order for us to feel comfortable saying this, though, we have to know what best practices are and how they are different from our current practices.

So what are best practices?

For opioid prescribing, best practices reduce the risk of overdose and misuse. Dr. Teryl Nuckols of the University of California, Los Angeles, and her colleagues published a systematic review of guideline recommendations related to mitigating the risk for accidental overdose and misuse (Ann. Intern. Med. 2013 Nov. 12 [doi: 10.7326/0003-4819-160-1-201401070-00732]). Thirteen guidelines informed the major conclusions, and all were published after 2009.

One risk mitigation strategy is having an upper dosing threshold that we do not violate. Evidence suggests that the risk for accidental overdose increases an estimated 1.9- to 3.1-fold with doses of 50- to 100-mg morphine equivalents, and even more dramatically with doses above 200 mg. Another strategy is to avoid prescribing methadone unless you are extremely comfortable with this medication, and to be careful with fentanyl because of unpredictable absorption with fever, exercise, or heat exposure.

Telling our patients that they can "have opioids or benzodiazepines, but not both" (especially if they are on more than 100 mg of morphine equivalents per day) can reduce risk, because 50% of accidental overdoses involve both. When switching opioids, reducing the dose of the equivalent opioids by 25%-50% is a safe practice, and free apps are available that can do this conversion for us.

Opioid contracts also may be helpful, and the use of screening tools (Current Opioid Misuse Measure) may inform our practice. Urine drug testing for the presence of the medication may be helpful to ensure adherence; the differential for a true negative is diversion, hoarding, or self-dosing leading to running out prematurely.

Concern about abuse is high, but data suggest that the absolute prevalence of this is low. Abuse occurs among 0.43%-3.27% of patients on chronic opioids, and addiction affects less than 0.05% (J. Pain Symptom Manage. 2008;35:214-28). Some experts suggest that trying to decipher abuse in the setting of chronic pain management with opioids is a "distinction without a difference."

Our main focus needs to remain on patient safety. We need to have honest conversations with our patients about mutual concerns and goals, and change discussions around appropriate dose reductions from "You want me to be in pain!" to "We need you to be safe."

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. He reports no conflicts of interest.

Prescription opioids remain a profound clinical challenge, and we as prescribing practitioners have a significant amount of control over this epidemic. About 14,000 people die from prescription opioid overdoses each year in the United States. Our good intentions to alleviate patient suffering are inextricably bound to the reality of potential iatrogenic harm.

As the corpus of knowledge around best practices for safe prescribing has evolved, hopefully we are evolving our practice for our own patients. But for patients whom we inherit from other practitioners or for those who have been in our practice for years on high doses of opioid analgesics, we need to become comfortable telling them, "Things are different now." In order for us to feel comfortable saying this, though, we have to know what best practices are and how they are different from our current practices.

So what are best practices?

For opioid prescribing, best practices reduce the risk of overdose and misuse. Dr. Teryl Nuckols of the University of California, Los Angeles, and her colleagues published a systematic review of guideline recommendations related to mitigating the risk for accidental overdose and misuse (Ann. Intern. Med. 2013 Nov. 12 [doi: 10.7326/0003-4819-160-1-201401070-00732]). Thirteen guidelines informed the major conclusions, and all were published after 2009.

One risk mitigation strategy is having an upper dosing threshold that we do not violate. Evidence suggests that the risk for accidental overdose increases an estimated 1.9- to 3.1-fold with doses of 50- to 100-mg morphine equivalents, and even more dramatically with doses above 200 mg. Another strategy is to avoid prescribing methadone unless you are extremely comfortable with this medication, and to be careful with fentanyl because of unpredictable absorption with fever, exercise, or heat exposure.

Telling our patients that they can "have opioids or benzodiazepines, but not both" (especially if they are on more than 100 mg of morphine equivalents per day) can reduce risk, because 50% of accidental overdoses involve both. When switching opioids, reducing the dose of the equivalent opioids by 25%-50% is a safe practice, and free apps are available that can do this conversion for us.

Opioid contracts also may be helpful, and the use of screening tools (Current Opioid Misuse Measure) may inform our practice. Urine drug testing for the presence of the medication may be helpful to ensure adherence; the differential for a true negative is diversion, hoarding, or self-dosing leading to running out prematurely.

Concern about abuse is high, but data suggest that the absolute prevalence of this is low. Abuse occurs among 0.43%-3.27% of patients on chronic opioids, and addiction affects less than 0.05% (J. Pain Symptom Manage. 2008;35:214-28). Some experts suggest that trying to decipher abuse in the setting of chronic pain management with opioids is a "distinction without a difference."

Our main focus needs to remain on patient safety. We need to have honest conversations with our patients about mutual concerns and goals, and change discussions around appropriate dose reductions from "You want me to be in pain!" to "We need you to be safe."

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. He reports no conflicts of interest.

Prescription opioids remain a profound clinical challenge, and we as prescribing practitioners have a significant amount of control over this epidemic. About 14,000 people die from prescription opioid overdoses each year in the United States. Our good intentions to alleviate patient suffering are inextricably bound to the reality of potential iatrogenic harm.

As the corpus of knowledge around best practices for safe prescribing has evolved, hopefully we are evolving our practice for our own patients. But for patients whom we inherit from other practitioners or for those who have been in our practice for years on high doses of opioid analgesics, we need to become comfortable telling them, "Things are different now." In order for us to feel comfortable saying this, though, we have to know what best practices are and how they are different from our current practices.

So what are best practices?

For opioid prescribing, best practices reduce the risk of overdose and misuse. Dr. Teryl Nuckols of the University of California, Los Angeles, and her colleagues published a systematic review of guideline recommendations related to mitigating the risk for accidental overdose and misuse (Ann. Intern. Med. 2013 Nov. 12 [doi: 10.7326/0003-4819-160-1-201401070-00732]). Thirteen guidelines informed the major conclusions, and all were published after 2009.

One risk mitigation strategy is having an upper dosing threshold that we do not violate. Evidence suggests that the risk for accidental overdose increases an estimated 1.9- to 3.1-fold with doses of 50- to 100-mg morphine equivalents, and even more dramatically with doses above 200 mg. Another strategy is to avoid prescribing methadone unless you are extremely comfortable with this medication, and to be careful with fentanyl because of unpredictable absorption with fever, exercise, or heat exposure.

Telling our patients that they can "have opioids or benzodiazepines, but not both" (especially if they are on more than 100 mg of morphine equivalents per day) can reduce risk, because 50% of accidental overdoses involve both. When switching opioids, reducing the dose of the equivalent opioids by 25%-50% is a safe practice, and free apps are available that can do this conversion for us.

Opioid contracts also may be helpful, and the use of screening tools (Current Opioid Misuse Measure) may inform our practice. Urine drug testing for the presence of the medication may be helpful to ensure adherence; the differential for a true negative is diversion, hoarding, or self-dosing leading to running out prematurely.

Concern about abuse is high, but data suggest that the absolute prevalence of this is low. Abuse occurs among 0.43%-3.27% of patients on chronic opioids, and addiction affects less than 0.05% (J. Pain Symptom Manage. 2008;35:214-28). Some experts suggest that trying to decipher abuse in the setting of chronic pain management with opioids is a "distinction without a difference."

Our main focus needs to remain on patient safety. We need to have honest conversations with our patients about mutual concerns and goals, and change discussions around appropriate dose reductions from "You want me to be in pain!" to "We need you to be safe."

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. He reports no conflicts of interest.