Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________
and inadequate patient counseling and monitoring, reflecting deficits in knowledge, competence, and performance [6]. Many primary care providers lack sufficient knowledge or training in pain medicine and in appropriate opioid use, and the majority report they do not feel confident managing chronic pain [7; 8]. A clinical skills assessment by the Ameri- can Academy of Family Physicians found significant and widespread knowledge deficits among family practice physicians in the medical skills necessary for providing optimal pain management, managing drug abuse and addiction, and utilizing risk evalu- ation and mitigation strategies when prescribing opioids [9]. The goal of this course is provide clinicians with an understanding of the essential components of appropriate opioid prescribing. This objective will be achieved through discussion of behavioral responses in patients receiving opioids for pain; the anteced- ents, catalysts, manifestations, and consequences of the dramatic and widespread increase in clinical and illicit use of prescription opioids; the assessment and management of pain; patient risk of developing problems with their prescribed opioid analgesic; gov- ernmental, law enforcement, and industry strategies and tactics to reduce prescription opioid abuse; and treatment approaches for patients with comorbid chronic pain and substance use disorders. Among primary care providers, there is great variability in the understanding of opioid use and misuse and in the confidence with which opioids are used for man- agement of chronic pain. Often, there is confusion or difficulty distinguishing physiological tolerance and dependence or uncontrolled pain behaviors from symptoms and signs of opioid use disorder. In addition to substantial differences in patient tolerability and analgesia with opioid analgesics, patients can also exhibit a range of psychological, emotional, and behavioral responses to prescribed opioids, the result of inadequate pain control, an emerging opioid use problem, or both. An apprecia- tion for the complexities of opioid prescribing, and the dual risks of litigation due to inadequate pain control and drug diversion or misuse, is necessary for all clinicians in order to provide the best possible patient care and to prevent a growing social problem.
INTRODUCTION In the United States, the use of prescription opioids for the treatment of pain is challenging and complex. There exists a prevailing tendency to inappropriate patterns of underprescribing (because of fear of adverse effects and addiction) or overprescribing (because of failure to select properly or frustration over a poor therapeutic response). These practice patterns are especially prevalent in the management of patients with chronic noncancer pain and have resulted in or contributed to unnecessary patient suffering from inadequately treated pain and increas- ing rates of opioid abuse, addiction, diversion, and overdose. Morphine was synthesized close to 200 years ago and entered clinical use more than 150 years ago. To this day, morphine and its opioid analogs remain the most powerful analgesics for severe acute pain and effective therapies for many chronic pain condi- tions. Opioid analgesic prescribing for pain control has risen dramatically since the late 1990s, and although opioid analgesic use in moderate-to-severe acute pain, cancer pain, and terminal pain is widely accepted, its use in chronic noncancer pain remains controversial [1]. Opioids can provide effective pain control, but problematic side effects are common, long-term outcomes vary, and escalating rates of addiction, diversion, and fatal overdose involving opioids have occurred in tandem with their increas- ing clinical use for pain control. These negative outcomes from increasingly widespread prescribing have heightened awareness of the need for prescrib- ers to mitigate the inherent risks that come with opioid analgesics in order to minimize their abuse, addiction, diversion, and fatal toxicity [2]. There is a shortage of pain specialist physicians in the United States that is expected to worsen, and this has resulted in most of the medical care for patients with chronic pain being delivered by primary care physicians [3]. The current problems involving pre- scription opioid analgesics are primarily the result of prescriber factors and the undue influence of stake- holders over pain medicine practice [4; 5]. Prescriber factors include inappropriate opioid prescribing
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MDMS1526
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