Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 1
Jonathan, 42, presents looking anxious and in considerable pain. A year ago, while moving furniture, he experienced sudden piercing mid-low back pain that radiated down his left leg. The patient had an L4/5 microdiscectomy that appeared at first to relieve radicular symptoms, but the symptoms returned six weeks afterward. His pain intensity at rest is 6 out of 10 on the VAS, but movement brings on back spasms, which causes his pain level to spike to 9 out of 10. Walking and bending at the waist are excruciating, and he finds it hard to find a comfortable position when lying down. He reports that ACET and ibuprofen bring no relief and admits that he would like to receive an ER formulation of oxycodone because he already knows it works for the pain, having occasionally used the same prescription belonging to a friend. Jonathan is now estranged from his parents, both of whom drank to excess and used illegal drugs when he was a child. He reports a history of panic attacks and nightmares ever since his time spent serving in the armed forces. He smokes approximately 30 cigarettes a day. He has no cardiopulmonary, gastrointestinal, endocrine, or neurologic diseases.
1. How might Jonathan’s pain type, intensity, duration and treatments tried inform the creation of a treatment plan for him?
2. What mental health screening tool(s) would be helpful?
3. What risk factors for opioid misuse are present and how might they influence treatment choices?
Guidelines and Regulations Governing Long- Term Opioid Therapy If, after a risk-benefit analysis, a trial of opioid therapy for chronic pain is warranted, HCPs have access to numerous guidelines developed by professional medical societies, states, and federal agencies to assist in setting and executing treatment plans. Common recommendations include: 20,61,77,85,138 • Start patients on the lowest effective dose • Conduct UDT at baseline and on follow-up as appropriate • Check PDMP at baseline and on follow-up as appropriate • Monitor pain and treatment progress with documentation, using greater vigilance at higher doses • Pay close attention to drug-drug and drug- disease interactions • Recognize special risks with fentanyl patches and methadone • Titrate slowly and cautiously • Consider using an opioid-specific risk assessment • Use safe and effective methods for discontinuing opioids (e.g., tapering, making appropriate referrals to substance abuse treatment or other services) To dispense any controlled substance, including opioids, HCPs must be registered with the DEA. Be aware also that each state may have laws and regulations that govern many aspects of opioid prescribing. Each HCP should check the laws and regulations within the state of practice and take care to comply with all requirements.
Applicable state regulations are evolving rapidly and contain restrictions and directives such as: 139 • Dose and treatment duration limits • Expanded PDMPs and new requirements for their use • Required continuing medical education • Required written pain treatment agreements • Required physical exam prior to prescribing • Required bona fide patient-physician relationship • Specified timing of follow-up visits and/or UDT • Presentation of patient identification to a pharmacist prior to receiving opioids • Medicaid plans requiring single prescriber and single pharmacy for certain high-risk patients Whenever federal and state law conflict, the more restrictive law applies. The Prescription Drug Abuse Policy System (PDAPS), funded by the National Institute on Drug Abuse, tracks key state laws related to prescription drug abuse here: http:// www.pdaps.org/. The CDC issued has a practice guideline for using opioids to treat patients who have chronic pain and do not have an active malignancy or need palliative or end-of-life care. 61 The guideline defines long-term opioid therapy as use of opioids on most days for greater than three months. Authors of the guideline state that its strictures should not be used to deny clinically appropriate opioid therapy to patients but, rather, to help HCPs in primary care consider all treatment options with an eye to reducing inappropriate opioid use. 140
Initiating or Continuing Long-Term Opioid Therapy
The HCP may consider a trial of long-term opioid therapy as one therapeutic option if the patient’s pain is severe and ongoing or recurs frequently, diminishing function or quality of life, and is unrelieved or likely to be unrelieved by non- opioid therapies. 77 To initiate a trial or continue opioid therapy, the HCP should complete the initial exam and diagnostic procedures and assess pain, mental-health, social, substance, and opioid risk as previously described. A list of items to document in the patient record is shown in Table 7. 20,61,77,85,138,141 Medical records should be kept up-to-date and be legible so as to be easily reviewed. Informed Consent Patients started on opioid therapy for chronic pain should be informed of the potential risks and benefits. The most serious risk with any opioid is respiratory depression leading to death. Patients who have never taken opioids or whose medications or doses will be changed should be counseled to expect sedation or other cognitive effects. An informed consent form should be signed by the HCP and the patient and retained in the medical record. Items recommended in informed consent include: 20,77,141 • Potential risks and benefits of opioid therapy • Risks of OUD, overdose, and death even at prescribed doses • That evidence is limited for benefit of opioids in chronic noncancer pain
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