Prescribe Chronic Opiates Safely and Efficiently

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.

Keep track of red flags for prescription drug misuse in one place in the patient’s file: That’s how to prevent signs of a pattern of problematic behavior from slipping through the cracks. One major red flag is a history of substance abuse.

"It’s super important to at least ask about alcohol or substance abuse and document it in the chart, recognizing that you may not get an honest answer," Dr. Gaster advised.

"Anyone with a history of substance abuse should be treated with opiates for bad somatic pain only with extreme caution. The risk of prescription drug abuse in someone who has a history of substance abuse is dramatically higher. This is a completely different class of prescribing. It’s hard to say such people should never be on chronic opiates, but a much, much higher level of caution is required," he said.

As for patients with an ongoing substance abuse problem who also have obvious severe somatic pain, on balance the risk of harm in prescribing chronic opiates exceeds the potential benefit.

"These are terrible situations. I’d say primary care doctors shouldn’t be doing this at all. Such patients should be offered a referral for substance abuse treatment," he said.

Hepatitis C infection is another major red flag because it’s an important epidemiologic indicator of past illicit drug use.

Use a urine toxicology screen: An "absolutely essential part of the tool kit" because it’s the only source of hard data regarding whether a patient is abusing or diverting prescription drugs. Do it randomly but fairly frequently, and let the patient know that any time a urine screen is ordered, leaving the clinic without providing a urine sample that day will be considered tantamount to a positive test and will result in discontinuation of opiate therapy.

"If you were to pick out the one thing on a urine toxicology screen that’s most informative, I’d say it’s a positive result for cocaine. Cocaine use has a very, very high correlation with prescription drug abuse, and there are virtually no false-positive results for cocaine," the internist said.

In contrast, false-positive results for amphetamines are a real problem. The ELISA assay for amphetamines turns out to have cross-reactivity with at least 20 prescription drugs, including bupropion, phenergan, and legitimate medications for attention-deficit/hyperactivity disorder. Having the lab run a gas chromatography test will differentiate prescription stimulant medications from illicit street amphetamines.

Another key point about urine toxicology screens is they don’t reliably detect synthetic opiates such as fentanyl, or semisynthetic opiates such as oxycodone.

"Patients taking oxycodone may very well have a negative toxicology result, so you always need to make sure to order a separate oxycodone assay as part of your toxicology screen," he advised.

Also, before bringing up the need for a urine screen that very day, be sure to ask when the patient took his last opiate pill. That will be most helpful in interpreting a negative result.

For patients on dialysis who are anuric, use serum drug testing.

Utilize the statewide prescription monitoring system: It’s an essential tool for detection of patients who are sneaking around and obtaining opiate prescriptions from multiple physicians and then selling them.

"The giant street market for prescription opiates is, to some extent, happening from pharmacies and warehouses being robbed, but the vast majority of those pills are coming from doctors’ offices," Dr. Gaster noted.

Stop chronic opiates in response to red flags: This is one of the most difficult and emotion-charged interactions that occur between physicians and patients. "I rank it right up there with having to deliver a cancer diagnosis," Dr. Gaster said.

Patients seldom take this news well, so it’s a good idea to practice this straightforward phrasing beforehand: "In my medical opinion, this type of pain medication is simply not safe for you and I cannot prescribe it for you anymore."

To avoid legal and ethical problems, it’s important to emphasize that patients are not being fired or abandoned. Explain that you’re willing to continue as the patient’s physician, but not in prescribing opiates, he said.

Dr. Gaster reported having no financial conflicts.

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.

Keep track of red flags for prescription drug misuse in one place in the patient’s file: That’s how to prevent signs of a pattern of problematic behavior from slipping through the cracks. One major red flag is a history of substance abuse.

"It’s super important to at least ask about alcohol or substance abuse and document it in the chart, recognizing that you may not get an honest answer," Dr. Gaster advised.

"Anyone with a history of substance abuse should be treated with opiates for bad somatic pain only with extreme caution. The risk of prescription drug abuse in someone who has a history of substance abuse is dramatically higher. This is a completely different class of prescribing. It’s hard to say such people should never be on chronic opiates, but a much, much higher level of caution is required," he said.

As for patients with an ongoing substance abuse problem who also have obvious severe somatic pain, on balance the risk of harm in prescribing chronic opiates exceeds the potential benefit.

"These are terrible situations. I’d say primary care doctors shouldn’t be doing this at all. Such patients should be offered a referral for substance abuse treatment," he said.

Hepatitis C infection is another major red flag because it’s an important epidemiologic indicator of past illicit drug use.

Use a urine toxicology screen: An "absolutely essential part of the tool kit" because it’s the only source of hard data regarding whether a patient is abusing or diverting prescription drugs. Do it randomly but fairly frequently, and let the patient know that any time a urine screen is ordered, leaving the clinic without providing a urine sample that day will be considered tantamount to a positive test and will result in discontinuation of opiate therapy.

"If you were to pick out the one thing on a urine toxicology screen that’s most informative, I’d say it’s a positive result for cocaine. Cocaine use has a very, very high correlation with prescription drug abuse, and there are virtually no false-positive results for cocaine," the internist said.

In contrast, false-positive results for amphetamines are a real problem. The ELISA assay for amphetamines turns out to have cross-reactivity with at least 20 prescription drugs, including bupropion, phenergan, and legitimate medications for attention-deficit/hyperactivity disorder. Having the lab run a gas chromatography test will differentiate prescription stimulant medications from illicit street amphetamines.

Another key point about urine toxicology screens is they don’t reliably detect synthetic opiates such as fentanyl, or semisynthetic opiates such as oxycodone.

"Patients taking oxycodone may very well have a negative toxicology result, so you always need to make sure to order a separate oxycodone assay as part of your toxicology screen," he advised.

Also, before bringing up the need for a urine screen that very day, be sure to ask when the patient took his last opiate pill. That will be most helpful in interpreting a negative result.

For patients on dialysis who are anuric, use serum drug testing.

Utilize the statewide prescription monitoring system: It’s an essential tool for detection of patients who are sneaking around and obtaining opiate prescriptions from multiple physicians and then selling them.

"The giant street market for prescription opiates is, to some extent, happening from pharmacies and warehouses being robbed, but the vast majority of those pills are coming from doctors’ offices," Dr. Gaster noted.

Stop chronic opiates in response to red flags: This is one of the most difficult and emotion-charged interactions that occur between physicians and patients. "I rank it right up there with having to deliver a cancer diagnosis," Dr. Gaster said.

Patients seldom take this news well, so it’s a good idea to practice this straightforward phrasing beforehand: "In my medical opinion, this type of pain medication is simply not safe for you and I cannot prescribe it for you anymore."

To avoid legal and ethical problems, it’s important to emphasize that patients are not being fired or abandoned. Explain that you’re willing to continue as the patient’s physician, but not in prescribing opiates, he said.

Dr. Gaster reported having no financial conflicts.

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.

Keep track of red flags for prescription drug misuse in one place in the patient’s file: That’s how to prevent signs of a pattern of problematic behavior from slipping through the cracks. One major red flag is a history of substance abuse.

"It’s super important to at least ask about alcohol or substance abuse and document it in the chart, recognizing that you may not get an honest answer," Dr. Gaster advised.

"Anyone with a history of substance abuse should be treated with opiates for bad somatic pain only with extreme caution. The risk of prescription drug abuse in someone who has a history of substance abuse is dramatically higher. This is a completely different class of prescribing. It’s hard to say such people should never be on chronic opiates, but a much, much higher level of caution is required," he said.

As for patients with an ongoing substance abuse problem who also have obvious severe somatic pain, on balance the risk of harm in prescribing chronic opiates exceeds the potential benefit.

"These are terrible situations. I’d say primary care doctors shouldn’t be doing this at all. Such patients should be offered a referral for substance abuse treatment," he said.

Hepatitis C infection is another major red flag because it’s an important epidemiologic indicator of past illicit drug use.

Use a urine toxicology screen: An "absolutely essential part of the tool kit" because it’s the only source of hard data regarding whether a patient is abusing or diverting prescription drugs. Do it randomly but fairly frequently, and let the patient know that any time a urine screen is ordered, leaving the clinic without providing a urine sample that day will be considered tantamount to a positive test and will result in discontinuation of opiate therapy.

"If you were to pick out the one thing on a urine toxicology screen that’s most informative, I’d say it’s a positive result for cocaine. Cocaine use has a very, very high correlation with prescription drug abuse, and there are virtually no false-positive results for cocaine," the internist said.

In contrast, false-positive results for amphetamines are a real problem. The ELISA assay for amphetamines turns out to have cross-reactivity with at least 20 prescription drugs, including bupropion, phenergan, and legitimate medications for attention-deficit/hyperactivity disorder. Having the lab run a gas chromatography test will differentiate prescription stimulant medications from illicit street amphetamines.

Another key point about urine toxicology screens is they don’t reliably detect synthetic opiates such as fentanyl, or semisynthetic opiates such as oxycodone.

"Patients taking oxycodone may very well have a negative toxicology result, so you always need to make sure to order a separate oxycodone assay as part of your toxicology screen," he advised.

Also, before bringing up the need for a urine screen that very day, be sure to ask when the patient took his last opiate pill. That will be most helpful in interpreting a negative result.

For patients on dialysis who are anuric, use serum drug testing.

Utilize the statewide prescription monitoring system: It’s an essential tool for detection of patients who are sneaking around and obtaining opiate prescriptions from multiple physicians and then selling them.

"The giant street market for prescription opiates is, to some extent, happening from pharmacies and warehouses being robbed, but the vast majority of those pills are coming from doctors’ offices," Dr. Gaster noted.

Stop chronic opiates in response to red flags: This is one of the most difficult and emotion-charged interactions that occur between physicians and patients. "I rank it right up there with having to deliver a cancer diagnosis," Dr. Gaster said.

Patients seldom take this news well, so it’s a good idea to practice this straightforward phrasing beforehand: "In my medical opinion, this type of pain medication is simply not safe for you and I cannot prescribe it for you anymore."

To avoid legal and ethical problems, it’s important to emphasize that patients are not being fired or abandoned. Explain that you’re willing to continue as the patient’s physician, but not in prescribing opiates, he said.

Dr. Gaster reported having no financial conflicts.