With medications that carry significant risks, such as opioids, appropriate prescribing practices are critical to patient safety. One physician in Boston lives by a mantra that puts patients first: Judge the treatment, not the patient.
We need to start re-conceptualizing chronic pain as a chronic disease, said Daniel P. Alford, MD, associate professor of medicine at the Boston University School of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program.
“Acute pain is a symptom, and it’s life-sustaining—and you need to feel acute pain in order to survive,” Dr. Alford said. But “there is no advantage to chronic pain. Chronic pain really is a malfunctioning of the nervous system and requires, like other chronic diseases, a multimodal approach.”
Many potential physical, psycho-behavioral, procedural and pharmacologic options exist for managing chronic pain. Dr. Alford follows a process that helps him to make the appropriate clinical judgment regarding whether or not opioids are an appropriate course of treatment for each individual patient:
Will patient's pain process respond to opioid therapy
For a lot of chronic pain disorders, opioids are probably not the answer, Dr. Alford said. “For example, chronic migraine headaches, fibromyalgia and back pain … tend to be less opioid responsive, and so I’d be reluctant to start them.”
For non-cancer chronic pain, opioids are indicated when pain is severe, has significant impact on function and quality of life and other treatments have been inadequate. “When you’ve tried other things and they haven’t been successful,” he said, “a trial with an opioid is appropriate.”
Prior to prescribing, do a risk assessment
Attempt to evaluate how risky it might be to prescribe opioids to the individual patient, Dr. Alford said. “There are opioid misuse risk stratification tools … including the opioid risk tool (ORT),” which are intended to classify patients as low, moderate and high risk for opioid misuse. But you cannot rely on these tools alone because they have not been rigorously tested.
They can help start the conversation about other known risk factors and predictors for problematic prescription opioids with the patient so that they’re informed about their risk, Dr. Alford said. “[This conversation] also helps you determine how to structure therapy and monitor them for safety—that is, if they’re at higher risk or misusing their opioids, then they need to be monitored more closely.”
Use universal precautions
Because no one can predict problematic behavior with absolute certainty, you have to “assume that every single person who’s prescribed opioids carries some risk for misusing that opioid,” Dr. Alford said. “Every one of my patients on chronic opioid therapy gets that initial risk assessment but also needs to be monitored for adherence and misuse.”
“The frequency of doing all those things,” he said, “is going to be based on your initial and ongoing assessment of their response to therapy, particular risks and behavior.”
Structure care and monitor the patient for safety
Over time, monitor the patient for adherence using objective information including checking the prescription drug monitoring program (PDMP), urine testing, pill counts and making sure the interval between visits is appropriate. “If the patient is doing well based on pain relief, function and daily activities,” he said, “then I’m going to be less worried about their potential misuse of opioids.”
At least a 30 percent improvement in pain and function is a reasonable goal.
“Even if the person appears to be benefitting,” he said, “if you start to get a sense that they are misusing the opioid—that is, loss of control, compulsive use, continued use despite harm, they keep running out early, showing up in the emergency room, calling the on-call service, or they become so focused on the drug they can’t even imagine doing anything else for their pain, or they’re having some negative consequences from the opioid but still want more—I would probably end up tapering that opioid because I just feel that it’s too unsafe.”
“These are all very difficult decisions to be made,” he said.
Prescribe opioids at the lowest dose possible
Dr. Alford said you should initiate therapy in a way that the patient understands that it is a test or a trial to see whether or not they will benefit from the treatment.
“If they’re not benefitting, then they may be in the portion of patients who are never going to benefit from an opioid because their pain is just not responsive to opioids” and the risks are too high, he said. “If they are responding, that’s encouraging—but I’m going to be very reluctant to increase the dose.”
As you increase the dose, the risk for overdose and other complications increases, Dr. Alford said. “If the patient is benefitting on the opioid, I want to try to maintain them on the lowest dose possible … keeping in mind that [with chronic pain] like other chronic diseases, I want to try to [use] other therapies concurrent to it, whether it be other medications, using rational polypharmacy or other non-pharmacological treatments like acupuncture, behavioral and physical treatments.”
Conceptually, treating chronic pain with opioids has to be viewed through the same lens as treating any other chronic disease with any other medication, Dr. Alford said. “That is, when I put someone on an antihypertensive for their blood pressure, I’m judging whether or not the treatment is working by measuring the person’s blood pressure and checking for adverse effects.”
“If it isn’t working, I’m not blaming the patient, saying this medication should work, but that patient is a bad person; they can’t take it right,” he said. “I’m judging the treatment both from a benefit and risk perspective.”
“Apply the same thing to opioids for pain,” he recommends. “Are the opioids helping the patient more than they’re hurting the patient? If that’s not the case, if I can’t be satisfied that the person is benefitting more than being harmed, then the treatment has failed—not the patient. … And it’s time to consider something else.”
“We need to put our clinician cap on and avoid becoming a police officer, or a DEA agent or a judge when it comes to opioids and chronic pain,” Dr. Alford said. “Chronic pain is a chronic disease, and opioids are one tool that benefits some patients but carries a whole lot of risk. And we should just treat it that way.”
Naloxone also can be a way to start the broader conversation about the risks that opioid medications carry without contributing to the stigma that surrounds overdose and substance use disorders.