Best Practices in Safe Ppioid Monitoring May Include
- Understand risks of opioid dose escalation
- Recognize the risks of combining opioids with other central nervous system depressants such as benzodiazepines
- Consider using a validated questionnaire to assess function, pain severity and interference with enjoyment of life as well as opioid misuse risk
Assess the following at each visit (“8 A’s”)
- Analgesia (is it helping reduce pain?
- Adverse effects (side effects?)
- Function including ability to perform Activities of daily living (ADLs) such as errands, home housework, attending social engagements or appointments, returning to work, etc.
- Presence of Aberrant drug-related behaviors
- Prescription monitoring program data, urine drug monitoring, assess for cravings
- Affect (how is mood?)
- Use of Adjuvants (what other non-opioid medications and strategies?)
- Adherence to therapy (taking as prescribed?)
- Access to multimodal treatment
AAPM & APS. The use of opioids for the treatment of chronic pain. A consensus statement. 1996.
Risks of Developing an Opioid Use Disorder when Prescribed an Opioid for Pain
- Studies including over 310,000 patients prescribed opioids showed fewer than 5% of patients develop iatrogenic dependence or misuse when prescribed opioids for pain.1
- A different study of over 1 million patients showed the rate of opioid misuse/addiction after surgery at less that 1%, with slightly higher rates for 15-24 year olds.2
- Higgins C, Smith BH, Matthews K. Incidence of iatrogenic opioid dependence or abuse in patients with pain who were exposed to opioid analgesic therapy: a systematic review and meta-analysis. Br J Anaesth. 2018;120:1335-44.
- Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018;360:j5790.
Should We Limit Opioid Use to Less than 90-100mg Morphine Equivalents (MME)?
- Defining a dose ceiling is controversial. There is no clear answer to this question that applies to all patients – and an individualized plan is necessary. Consensus statements, such as from the Centers for Disease Control (CDC) in 2016, do recommend setting limitations to daily opioid dosing.1
- In a study of 2 million patients prescribed opioids, 0.02% died of an overdose2
- There was a dose-dependent effect seen above 200 mg/day MME but not at 100 mg/day MME or 120 mg/day
- Benzodiazepines in particular increase the risk of opioid overdose 10-fold
- Toxicology results indicate however, that 25% of overdose deaths involve more than one opioid, and 66% of overdoses are likely linked to illicit opioids3-4
- In addition to the risks and side effects associated with chronic high dose opioid therapy, higher doses of opioids have been suggested to lead to increased pain sensitivity, or hyperalgesia.
- Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recommendations and Reports.18;65(1):1-49.
- Dasgupta N, Funk MJ, Proescholdbell S, et al. Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain Med. 2016 Jan;17(1):85-98
- Hedegaard H, Warner M, Miniño AM. Drug Overdose Deaths in the United States, 1999–2016. NCHS Data Brief No. 294. https://www.cdc.gov/nchs/data/databriefs/db294.pdf
- Rudd RA, Seth P, David F, Scholl L. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445-1452
Possible Measures to Monitor and Address Adherence to Opioid Medications
- Implement and periodically review with the patient a written controlled substance treatment agreement.
- Perform periodic urine drug monitoring (frequency based on patient risk factors, but at least every 6-12 months to confirm the presence of the prescribed medication and monitor for other substances)
- Provide in-person patient consultations to monitor side effects and safe use (visit frequency based on patient risk), at least once very 3-4 months.
- Perform pill/patch counts.
- Review the state prescription monitoring program database (to assess appropriate refill dates, numbers of prescriptions/prescribers, other controlled substance prescriptions, etc.) and counsel the patient on the results to reinforce adherence.