______________________________ Strategies for Appropriate Opioid Prescribing: The Florida Requirement
For acute pain episodes, effective opioid stewardship begins with recognizing that vaso-occlusive crises represent genuine severe, acute pain, and that undertreatment carries real clinical risk. Management should follow a protocol-driven approach; prompt assessment, rapid initiation of IV morphine or hydromorphone for severe pain, and frequent reassessment every 15–30 minutes with dose titration based on the patient’s response. Management typically requires stronger analgesic agents, with codeine and tramadol useful for moderate pain and morphine, oxycodone, hydrocodone, and hydromorphone more effective in treating severe and breakthrough pain [101]. With recurrent pain, the best initial choice of opioid and dose for severe sickle cell pain is that which previously provided adequate analgesia [101]. For chronic pain associated with sickle cell disease, long-acting and short-acting opioids, NSAIDs and acetaminophen, and adjuvant medications form the basis of long-term management [104]. In patients requiring chronic opioid therapy, extended- release, sustained-release, or long-half-life opioid formulations are favored because of ease in administration and more consistent analgesia. Adjunctive therapy with SNRIs and TCAs can alter pain perception in the spinothalamic tract [101; 102]. From a stewardship perspective, patients with recurrent crises benefit from individualized pain management plans documented in the medical record; this reduces care delays, standardizes treatment, and minimizes prescribing variability. Critically, opioid stewardship in sickle cell disease must also actively counter the stigmatization and implicit bias that put these patients at risk of undertreatment. A stewardship- informed approach supports equitable, evidence-based care that prioritizes adequate pain relief while maintaining appropriate monitoring for sedation and respiratory depression. PATIENT EVALUATION AND ASSESSMENT OF ADDICTION RISK Information obtained by patient history, physical examination, and interview, from family members, a spouse, or state prescription drug monitoring program (PDMP), and from the use of screening and assessment tools can help the clinician to stratify the patient according to level of risk for developing problematic opioid behavioral responses ( Table 1 ). Low-risk patients receive the standard level of monitoring, vigilance, and care. Moderate-risk patients should be considered for an additional level of monitoring and provider contact, and high-risk patients are likely to require intensive and structured monitoring and follow-up contact, additional consultation with psychiatric and addiction medicine specialists, and limited supplies of short-acting opioid formulations [44; 58]. Anxiety disorders, major depressive disorder, and intense emotional distress alter pain perception and response. Intensity and perception of reported pain is also influenced by factors such as mood, cultural background, social supports, and financial resources. A biopsychosocial model is required to inform pain assessment in order to address the biologic basis of pain and presence of social and psychologic contributors [51].
Before deciding to prescribe an opioid analgesic, clinicians should perform and document a detailed patient assessment that includes [1]: • Pain indications for opioid therapy • Nature and intensity of pain • Past and current pain treatments and patient response • Comorbid conditions • Pain impact on physical and psychologic function • Social support, housing, and employment • Home environment (i.e., stressful or supportive) • Pain impact on sleep, mood, work, relationships, leisure, and substance use • Patient history of physical, emotional, or sexual abuse Depression is perhaps the single most important comorbidity in patients with chronic pain and is vastly underdiagnosed and untreated. Patients with unrecognized and untreated depression are unlikely to respond to opioids and other pain therapies, but successful treatment of depression can promote analgesia [62]. If substance abuse is active, in remission, or in the patient’s history, consult an addiction specialist before starting opioids [1]. In active substance abuse, do not prescribe opioids until the patient is engaged in a treatment/recovery program or other arrangements made, such as addiction professional co-management and additional monitoring. When considering an opioid analgesic (particularly those that are extended-release or long-acting), one must always weigh the benefits against the risks of overdose, abuse, addiction, physical dependence and tolerance, adverse drug interactions, and accidental exposure by children [44; 63]. Screening and assessment tools can help guide patient stratification according to risk level and inform the appropriate degree of structure and monitoring in the treatment plan. It should be noted that despite widespread endorsement of screening tool use to help determine patient risk level, most tools have not been extensively evaluated, validated, or compared to each other, and evidence of their reliability is poor [64]. Opioid Risk Tool (ORT) The Opioid Risk Tool (ORT) is a five-item assessment to help predict aberrant drug-related behavior. The ORT is also used to establish patient risk level through categorization into low, medium, or high levels of risk for aberrant drug-related behaviors based on responses to questions of previous alcohol/ drug abuse, psychologic disorders, and other risk factors [65; 66].
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