__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use There is also considerable evidence that, in the past, major stakeholders have negatively influenced the delivery of safe, effective, and appropriate anal- gesic care to patients with chronic pain. This has occurred, in part, through bias of the information provided to clinicians to guide their practice and prescribing behavior with respect to opioid analge- sics. Effective practice is based on training, clinical judgment, and ongoing study of advances in practice areas. Careful clinicians pay attention to published research and other mediums of knowledge transfer that are relevant to their particular practice, with a trained eye toward the quality of evidence. Unfortu- nately, much of what has been published on chronic pain management, especially as regards opioid drug use, has uncertain validity because of various forms of bias and nonrigorous statistical analysis. This has had an adverse impact on the consistency and quality of care, on clinician confidence in how to render care, and on the public health cost of opioid analgesic care. For these reasons, an Appendix to this course has been included to provide some his- torical perspective on opioid prescribing practices and to address sources of bias in clinical (therapeu- tic) research. and to minimize patient risk of abuse, addiction, and fatal toxicity. The foundation of appropriate opioid prescribing is based on thorough patient assessment, treatment planning, and follow-up and monitoring. Essential for proper patient assessment and treatment planning is comprehension of the clinical concepts of opioid abuse and addiction, their behavioral manifestations in patients with pain, and how these potentially problematic behav- ioral responses to opioids both resemble and differ from physical dependence and pseudodependence. Prescriber knowledge deficit has been identified as a key obstacle to appropriate opioid prescribing and, along with gaps in policy, treatment, attitudes, and research, contributes to widespread inadequate treat- ment of pain [7]. A 2013 survey measured primary care physician understanding of opioids and addic- tion. Of the 200 participants, [11]: • 35% admitted knowing little about opioid addiction. • 66% and 57% viewed low levels of education and income, respectively, as causal or highly contributory to opioid addiction.
• 30% believed opioid addiction “is more of a psychological problem,” akin to poor lifestyle choices rather than a chronic illness or disease. • 92% associated prescription analgesics with opioid addiction, but only 69% associated heroin with opioid addiction. • 43% regarded opioid dependence and addiction as synonymous. This last point is very important because confu- sion and conflation of the clinical concepts of dependence and addiction has led to accusations of many nonaddicted patients with chronic pain misusing or abusing prescribed opioids and to fail- ure to detect treatment-emergent opioid problems [12]. Knowledge gaps concerning opioid analgesics, addiction, and pain may be related to attitude gaps, and negative attitudes may interfere with appropriate prescribing of opioid analgesics. For example, when 248 primary care physician survey participants were questioned regarding their prescribing approach in patients with headache pain and either a past or
DEFINITIONS Definitions and use of terms describing opioid analgesic misuse, abuse, and addiction have changed over time, and their current correct use is inconsis- tent not only among healthcare providers, but also among federal agencies reporting epidemiological data such as prevalence of opioid analgesic misuse, abuse, or addiction. Misuse and misunderstand- ing of these concepts and their correct definitions has resulted in misinformation and represents an
impediment to proper patient care. OPIOID ABUSE, DEPENDENCE, AND ADDICTION
Inappropriate opioid analgesic prescribing for pain is defined as the nonprescribing, inadequate prescrib- ing, excessive prescribing, or continued prescribing despite evidence of ineffectiveness [10]. Appropri- ate opioid prescribing is essential to achieve pain control, to minimize societal harms from diversion,
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MDMS1526
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