Setting Up an Opiate Therapy Program for Chronic Pain
Chronic pain is a subjective perception without clinically measurable effects in most cases.
Therefore many physicians will not prescribe opiate narcotics as a treatment for pain since it
cannot be validated and because of the risk of substance abuse. Arguments against opiate
prescribing are often based on misconceptions regarding pseudoaddiction or fear of the
DEA/State Medical Boards. On the other extreme, some physicians erroneously claim
patients have a right to narcotic pain medicine in whatever doses are necessary to keep the
patient's comfortable. These physicians quote studies showing absurdly low rates of
substance abuse and equate the presence of pain solely with an inadequate supply of opiates.
As is often the case, the truth lies somewhere in between.
Chronic pain is associated with substance abuse ranging from <1% to 50% depending on
the study. The most poorly constructed studies take a selected population without any abuse
history, monitor them only by asking the patient if they have engaged in any substance
abuse, and are often using relatively low dose narcotics. Physicians who are staunch
proponents of opiates will then extrapolate these erroneous study results into conclusions
that opiates are safe and effective. Well controlled studies are long term (more than 1-3
years) and query not only the patient regarding substance abuse, but also query the regional
pharmacies regarding doctor shopping, etc. in addition to requiring random drug screens.
The rates of substance abuse in such scenerios is not a paltry 1% but instead is well over
25%.
The disadvantage of prescribing opiates for chronic pain in an office setting are: 1. greater
paperwork requirements since patient monitoring becomes mandatory, especially with higher
doses. 2. Telephone calls regarding narcotic issues are still of a significant number, even
when a tight narcotic policy is imposed. 3. Substance abusers will flock to the door of new
pain centers 4. Substance diversion will become a chronic issue in the practice 5. Some
physicians in the community believe patients should under no circumstances receive chronic
opiates and may not refer patients to your practice. 5. Patients at higher doses may develop
significant side effects of daytime sedation, become a danger to themselves and others when
attempting to operate vehicles, are at higher risks of overdose due to their insouciant
attitudes partially promulgated by physician laxity in low dose prescribing (eg. patient
prescribed three 5mg oxycodone a day, but without notifying the physician, takes 6 a day
which is an increase of 100% over what is prescribed, but is only 15mg extra....hardly
enough to produce any overdose. The physician does not speak with the patient about their
abuse of the medications, and instead escalates the dose thinking pseudoaddiction. One
year later, the same patient is now being prescribed three 80mg Oxycontin but instead takes
6- again a 100% increase, but now is a 240mg increase in the dose. This is certainly enough
to cause an overdose in many patients. The failure of the physician to vigorously enforce the
narcotic policies of the clinic ultimately result in enabling the patient later on to potentially
take a lethal dose of the drug.) 6. The differences in ethical and moral compasses between
the working population and the the Medicaid/non-employed-self-pay populations cannot be
overemphasized. Patients in the latter group have little left to lose, and will far more
frequently sell the narcotics on the street or abuse the narcotics vs. the population that has
much to lose from such behavior. Therefore extreme caution must be used in giving salable
drugs to this population, especially in light of the methamphetamine addiction epidemic which
is disproportionally affecting the poor. Salable drugs are being used frequently to trade for
methamphetamine or to sell, then purchase methamphetamine.
Advantages of opiate prescribing to certain chronic pain patients without a substance
abuse history may permit their continued working in full time employment and reduction in
the numbers of patients who would otherwise cost taxpayers enormous sums of money by
entering the rapidly growing social security disability system. Patients receiving moderate
amounts of opiates may be more lucid, are able to concentrate more due to a reduction in the
interfering pain, and may have a more functional lifestyle. At times, depression and chronic
anxiety are reduced in a subset of the chronic pain population receiving chronic opiate
therapy.
Therefore, when the balance in your clinic's situation is such that opiate prescribing for
some of the chronic pain population is advantageous and the logistics of the operation are
reasonably controllable, then you may wish to offer this service, especially given that a pain
physician should have more expertise in the area than any other physician.
Patient selection is reviewed under other sections of this part of the website.
SETTING UP THE OPIATE PRESCRIBING SYSTEM
1. Patients must understand that pain may not respond to opiates, and that in such cases,
you WILL withdraw the opiates if there are no significant improvements in response rate with
escalating doses.
2. Patient should be given a target of 50-75% pain relief. Relief of 100% of the pain is
rarely possible and is not a goal given the proclivity to develop escalation of doses once the
patient is used to 100% pain relief.
3. Patients must understand receiving opiate therapy is not a right and has certain risks
attached of sedation, constipation, respiratory depression, death, etc. These should be
included in the signed opiate agreement. The rules under which opiates may be withdrawn
gradually or stopped suddenly should be spelled out clearly in the opiate agreement. (See the
opiate agreements on this section of the website)
4. All physicians, nurse practitioners, and prescribing physicians assistants in the clinic must
agree to a uniform policy of interpretation and enforcement of the opiate agreement. There
can be no deviation. If there is a question regarding interpretation, ask one of the other
practitioners how the situation should be handled. The staff is to reiterate the policy of the
practice to the patient, however if the patient is insistent, then questions about the policies
should be addressed to the physicians in the practice.
5. Enforcement mechanisms must be in place when patients are receiving moderate to high
dose opiates (>60mg/day oxycodone. These include random drug screening, event triggered
drug screening, mandatory pill counts either at your office or by the pharmacist at their local
pharmacy, surveys of the local pharmacies the patient has visited (may require HIPPA
modification), insurance or Medicaid contact to find out where , from whom, and how many
narcotics are being prescribed, close contact with the PCP regarding any substance abuse
issues, employment of psychological counsel as a mandatory part of the patients therapy in
cases of severe psychological aberrations or substance abuse past or present, contact with
any ancillary physicians who might possibly be prescribing opiates (no HIPPA release is
required since these are treating physicians), notation of substance abuse alleged by other
patients or anonymous telephone calls, notation of diversion by the police and approprate
action taken. Physicians who prescribe high dose opiates must have access to the
prescriptions written for that patient at all times, 24 hours a day. This may require going to
the clinic and pulling the prescriptions in case an emergency department calls you at night or
having 24 hour availability of the same information through electronic medical records.
6. Patients who are given a timeframe with which to obtain the UDS must do so within that
time frame or they will not be prescribed any more opiates into the future, period. It is
recommended this policy carry over for at least one year before opiate prescribing is again
revisited.
7. If the staff is frequently beset by telephone calls about lack of adequate pain control, set
up an urgent followup with the patient. If the patient continues to call several times a day,
an administrative discharge of the patient may be employed. If patients frequently push the
physician into uncomfortable territory, tell the patient you are not willing to make such
changes as requested. If they persist or demonstrate a lack of understanding when you tell
them "no", it may be time for the patient to find another pain center.
8. Adopt a clinic policy on how narcotic issues are to be handled (such as preauth of drugs,
early refill calls, etc) and handle disputes with patients over narcotics, calmly and with
explanation. If the patient is unreasonably persistent, demanding narcotics in the clinic "or
else...", it is time to call the police in to the situation.
9. Substance abusers are not only from poor financial situations, but may be from the
wealthy or the socially connected. Often the most trouble is given by the "ritch witch" who
believes clinic rules simply do not apply to them.
10. Set up the paperwork (opiate agreement, drug screening handling, follow up assessment
form which should include both pain assessment and functional assessment), be certain
everyone (staff, secretaries, physicians, NP, PAs) in the clinic is on the same page with
respect to the rules, and DO NOT DEVIATE FROM THE RULES. Deviation may lead to
litigation due to unfair treatment, discrimination, etc.