RESPONSIBLE OPIOID PRESCRIBING

Responsible prescribing involves individual prescribers following best practices and taking action to balance the risks and benefits of opioid pain management for each patient. Important components to responsible prescribing include:

• Thorough patient assessment
• Treatment plan design
• Periodic monitoring
• Following evidence-based prescribing guidelines

Patient Assessment

A thorough patient assessment is critical prior to prescribing opioid medication for chronic pain. It is important to properly diagnose the condition to determine if opioid medication is an appropriate treatment. A well-documented patient history that includes past medical history, medication history, social history, family history, and psychosocial history is critical. Assessing and documenting a personal or family history of substance misuse is also important.

ASSESSING PAIN

Proper diagnosis of the painful condition helps to assure that opioid medication is an appropriate treatment. It can be challenging, however, since pain is subjective and multidimensional. The patient’s self-report of pain is the most reliable indicator, recognizing that perceptions of pain are influenced by culture, environment, emotional state, sleep patterns, and habits.

Any provider must conduct a pain assessment before they can determine what type of pain management is needed. Assessment of pain should include:

• Context (How did the pain begin?)
• Location (Where is the pain felt?)
• Severity (How does the pain rate on a 0–10 scale?)
• Quality (Is the pain sharp, stabbing, dull, pulsating, etc.?)
• Timing (How often does the pain occur?)
• Duration (How long has the pain been persisting?)
• Modifying factors (What makes the pain better or worse?)
• Chronic illness status (What conditions might impact or worsen the pain?)
• Associated signs and symptoms (What else occurs with the pain?)

ASSESSING RISK

When clinicians assess patients with chronic pain, it is important to recognize two categories of risk due to opioid therapy: medical conditions that increase their risk for adverse events (e.g., respiratory depression) and risk of misuse, abuse, or addiction.

Risk of Adverse Events

Risk due to medical conditions are assessed and documented as part of the patient’s history and physical examination and the treatment plan adjusted accordingly to reduce risk of adverse events with opioid therapy. Older adults may be at higher risk because of cognitive decline and increased potential for falls. Patients with impaired renal or hepatic function, cardiopulmonary disease, mental health conditions, obesity, and sleep apnea are also at higher risk for adverse consequences when prescribed opioid medications.

Risk for Misuse, Abuse, and Addiction

Variables that have been associated with a higher risk for misuse, abuse, and addiction include history of addiction in biological parents, current drug addiction in the family, regular contact with high-risk groups or activities, and personal history of illicit drug use or alcohol addiction. (See also “Recognizing Aberrant Drug-Related Behaviors” later in this course.)

The use of screening tools is recommended, and multiple tools are available that can help healthcare providers to assess these risks. The specific tool to be used is determined based on:

• The type of substance of risk (or whether the patient is at a generalized risk to misuse numerous substances)
• The age of the patient (as certain tools are specific to children or adolescents)
• Whether it is preferred to have the patient self-administer the screening or to have a healthcare professional do so

Examples of screening tools include:

• Opioid Risk Tool: Administered at initial visit prior to beginning opioid therapy; questions address age, family, and personal history of substance abuse, history of preadolescent sexual abuse, and psychological diseases
• Screening to Brief Intervention (S2BI): A series of questions regarding frequency-of-use in adolescent patients of substances most commonly used
• Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS): A combined screening and brief assessment that addresses use-related behaviors and generates a risk level for each substance class

(See also “Resources” at the end of this course.)

Treatment Plan

Responsible opioid prescribing requires clinicians to develop treatment plans that focus on patient-centered outcomes that improve quality of life. A function-based treatment strategy that aims to maximize the patient’s quality of life and minimize the burden of their pain includes a mutual understanding between prescriber and patient covering the following principles:

• Complete elimination of all pain is often not possible.
• The goal of treatment is to successfully manage pain and not exclusively to reduce a pain scale score.
• Functional goals will be collaboratively set, with the aim of improving quality of life; these goals must be realistic, achievable, verifiable, and meaningful.
• Risks, benefits, side effects, and potential adverse consequences of opioid use will be fully disclosed.
• Education about safe use, storage, and disposal of opioid medication will be provided.

This treatment plan must be documented, together with informed consent and patient education.

Periodic Monitoring

It is critical to regularly reevaluate the appropriateness of continuing opioid therapy due to changes in pain etiology, health condition, progress toward functional goals, and addiction risk. To corroborate self-reports, review of data within the prescription drug monitoring program should be conducted at each visit (see “Prescription Drug Monitoring Programs” later in this course). Periodic monitoring should also include urine tests and pill counts when appropriate.

Clinicians must utilize screening and monitoring for all patients on chronic opioid therapy to document patient outcomes and progress toward functional goals. The Pain Assessment and Documentation Tool (PADT) is a practical tool that clinicians can use at each patient visit and incorporate into electronic records (see “Resources” at the end of this course). It offers a simple checklist to monitor the “Five As” of pain management.

THE FIVE As OF PAIN MANAGEMENT

(Bazzo et al., 2019)
Analgesia	A reduction in pain
Activities of daily living	Improvement in level of function
Affect	Changes in mood
Adverse effects	Falls, decreased cognitive function, constipation, etc.
ADRBs	Aberrant drug-related behaviors

Periodic monitoring timing will vary with each patient. The CDC (n.d.) recommends checking monitoring every three months at the minimum, and before refilling an opioid prescription at any time. State requirements may vary. The State of West Virginia Office of the Attorney General’s “Best Practices for Prescribing Opioids in West Virginia” (2016) follows the exact same periodic monitoring timing as the CDC.

Guidelines for Prescribing Opioids for Chronic Pain

In 2022, the CDC updated its Clinical Practice Guideline for Prescribing Opioids for Pain. Whereas the 2016 guideline focused on recommendations for primary care physicians, the newer guideline expands the scope to additional clinicians whose scope of practice includes prescribing opioids (e.g., physicians, nurse practitioners and other advanced-practice registered nurses, physician assistants, and oral health practitioners). The 2022 guidelines address four main issues, including:

• Making a determination about whether or not to initiate opioids for pain
• Selecting the appropriate opioid and determining the dosage
• Deciding the duration of the initial opioid prescription and conducting follow-up
• Assessing the risk and addressing the potential harms of opioid use with the patient

The recommendations in the 2022 guidelines aim to improve communication between clinicians and patients about the risks and effectiveness of pain treatment; improve pain, function, and quality of life for persons with pain; and reduce the risks associated with opioid pain treatment (including opioid use disorder, overdose, and death) as well as with other pain treatment.

The practice guidelines include 12 recommendations for clinicians who are prescribing opioids for outpatients ages 18 years and older with pain that is acute (duration of <1 month), subacute (duration of 1–3 months), or chronic (duration of >3 months), excluding pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care (Dowell et al., 2022).

Likewise, in 2016, a diverse panel of West Virginia experts was convened to build upon the 2016 CDC guidelines for prescribing opioids for chronic pain. The panel developed its Safe and Effective Management of Pain (SEMP) Guidelines for prescribers and dispensers, with a focus on clinical treatment of pain and risk reduction strategies. Its pain treatment algorithms provide the best course of action for progression through escalating levels of pain based on current evidence and experience. These algorithms are meant to be referred to along with the CDC guidelines (CDC, 2017; WVEPMP, 2016).

The SEMP guidelines provide healthcare professionals with a risk reduction process to improve patient care and minimize provider anxiety. The twelve elements of this risk-reduction strategy include:

• Opioid risk screenings
• Drug interaction and pharmacologic review
• Pain reduction and function improvement goal
• End of therapy goal
• Initial and annual psychological evaluations
• Proper medication storage and disposal
• Naloxone prescribing and administration
• Prescription drug monitoring program (PDMP)
• Urine drug screening/testing
• Pill counts
• DEA “red flags”
• Patient and provider agreements
  (WVEPMP, 2016)