II. Contraindications: Relative

  1. Substance Abuse (especially Narcotic Abuse)
  2. Severe character pathology or Personality Disorder
  3. Chaotic social environment

III. Adverse Effects

  1. Cardiovascular events (including sudden death)
    1. QT Prolongation occurs most commonly with Methadone, Buprenorphine, Oxycodone
    2. Avoid combining with other agents that potentiate arrhythmia risk (e.g. Methadone and Diazepam)
  2. Constipation and Abdominal Pain
    1. See Opioid Induced Constipation
  3. Major Depression and Suicidality Risk
    1. Major Depression risk increases 25% with use >90 days and 50% with use >180 days
      1. Scherrer (2014) J Gen Intern Med 29(3):491-9 +PMID:24165926 [PubMed]
    2. Avoid combining Opioids with other CNS Depressants
    3. Limit Opioid dosing and quantity with appropriate follow-up
    4. Monitor for aggression and impulsivity (Suicidality risks)
    5. Encourage mental health referral (also beneficial in Chronic Pain Management)
    6. Use Antidepressants as appropriate, but avoid agents with risk in Overdose (e.g. Tricyclic Antidepressants)
  4. Hypothalamic-Pituitary hypofunction
    1. Decreases gonadal hormones including testosterone
    2. Consider obtaining hormone levels prior to initiating Chronic Opioids
    3. Buprenorphine has less hormone suppression than Methadone
    4. Hormonal levels improve on tapering Opioid dose
    5. Rhodin (2010) Clin J Pain 26(5):374-80 +PMID:20473043 [PubMed]
  5. Opioid-Induced Hyperalgesia
    1. Opioids may paradoxically worsen pain with chronic use
    2. Taper dose and re-evaluate after Opioid Withdrawal completed at 2-4 weeks
  6. Opioid Misuse and abuse
    1. See Complications below
    2. Refer to pain management
    3. Refer to Chemical Dependency
    4. Naloxone prescription for home (for emergency prn use)
    5. Suboxone is less likely to be misused or abused (but can still be abused via snorting or IV)
  7. Opioid Dependence and tolerance
    1. Taper Opioids
    2. Treat Opioid Withdrawal with non-controlled substances (e.g. Antiemetics, muscle relaxants, Clonidine)
    3. Do not exceed >120 mg/day of total morphine equivalents
    4. Involve pain management to consider transition to other agents or tapering medication
  8. Opioid Overdose and apnea risk
    1. Limit or taper Opioids if comorbid apnea risk (Sleep Apnea, binge drinking or excessive Alcohol use)
    2. Avoid combining CNS depressants (e.g. Benzodiazepines)
    3. Caution patients not to cut patches, crush or chew long-acting Opioids (and other misuse)
    4. Naloxone prescription for home (for emergency prn use)

IV. Complications

  1. Overdose Risk Factors
    1. Sleep Apnea
    2. Congestive Heart Failure
    3. Lung disease
    4. Sedative-Hypnotics (e.g. Benzodiazepines)
    5. Problem Alcohol use
    6. Comorbid psychiatric illness (e.g. Major Depression)
  2. Opioid misuse or Opioid Use Disorder Risk Factors
    1. See Opioid Risk Tool
    2. Narcotic Seeking Behavior
    3. Personal or Family History of Substance Abuse
    4. Psychiatric comorbidity
    5. Preadolescent history of sexual abuse

V. Guidelines: Chronic Opioid Use Guidelines in Non-Cancer Chronic Pain

  1. Observe for Narcotic Seeking Behavior
    1. See Prescription Drug Monitoring Programs link below
  2. Avoid confusing Pseudo-addiction for addiction
    1. Avoid inadequate treatment of pain
  3. Single clinician should primarily manage patient
  4. Incorporate Narcotic Contract consistently (renew annually)
  5. Maintain Narcotic use flow sheet
  6. Titrate to pain relief and adverse effects
    1. Reevaluate on a 1-4 week basis
  7. Documentation is key (see follow-up below)
  8. Convert short-acting Opioids to long-acting Opioids
    1. Use long-acting Narcotics around the clock
    2. Use short-acting Narcotics for breakthrough pain
      1. Prescribe only a relatively small number of short acting doses per month (e.g. 10 per month)
  9. Use in combination with other therapy
    1. See Chronic Pain Management
    2. Non-Opioid Analgesics
    3. Make use of non-pharmacologic modalities
  10. Treat Narcotic adverse effects prophylactically
    1. See Bowel Regimen in Chronic Narcotic Use
  11. Be aware of pseudotolerance
    1. Opioid appears to fail to control pain
    2. Pain flares are countered with escalated dosing and not returning to prior baseline
    3. Set expectations with patient
      1. Medication returns to prior baseline after brief flare
      2. Unauthorized dosage increases are not allowed

VI. Protocol: Initial Assessment for non-cancer pain Chronic Opioid therapy

  1. Select appropriate patients for Chronic Opioids
    1. Screen patients for Opioid misuse or Opioid Abuse
    2. See DIRE Score
    3. See Opioid Risk Tool
    4. Ask CAGE Questions
  2. Select appropriate conditions for Chronic Opioids
    1. Opioid responsive conditions (partially)
      1. Musculoskeletal pain
      2. Peripheral Neuropathy
      3. Postherpetic Neuralgia
    2. Opioid poorly responsive conditions (visceral pain, central pain)
      1. Chronic Abdominal Pain
      2. Chronic Pelvic Pain
      3. Fibromyalgia
      4. Headaches
  3. Select appropriate agent
    1. Start with short-acting Opioids
    2. MS Contin (Morphine long acting)
      1. Preferred
      2. Avoid in Renal Failure
    3. Oxycontin (Oxycodone long acting)
      1. High abuse potential
    4. Transdermal Fentanyl
      1. Expensive, risk of tolerance, variable absorption
    5. Methadone
      1. Very effective, with less tolerance risk and inexpensive
      2. Do not prescribe to patients at risk for Overdose (increased risk of death)
        1. Ray (2015) JAMA Intern Med 175(3):420-7 [PubMed]
      3. Requires knowledgable prescriber familiar with agent
      4. Risk of QT Prolongation
    6. Buprenorphine (transdermal or combined with Naloxone in Suboxone SL)
      1. Effective Analgesic with lower tolerance risk and lower abuse risk
      2. Requires special prescriber training, and is expensive
  4. Complete prerequisites at initial visit
    1. Controlled Medication Agreement (Narcotic Contract)
    2. Urine Drug Screen
  5. Educate regarding expectations
    1. Review pain control expectations
      1. Expect a 20% pain reduction at best
      2. See Chronic Pain Management
    2. Review escalating and tapering the dose
    3. Review rules and protocol when non-compliant
  6. Review Chronic Pain Flare Management
    1. Flares are same pain type and same location with an increase in intensity

VII. Protocol: Follow-up Visits

  1. Schedule follow-ups
    1. Initial: Reevaluate on a 1-4 week basis
    2. Later: Reevaluate every 3 months
  2. Documentation: 4A's
    1. Analgesia
      1. Document pain level (scale of 1 to 10)
    2. Adverse Effects
      1. Document Opioid side effects (e.g. Constipation, Nausea or Vomiting, Sedation)
    3. Activity Level
      1. Document functional status
      2. Following regular Exercise?
        1. See Exercise in Chronic Pain
    4. Adherence
      1. Annually renew Controlled Medication Agreement (Narcotic Contract)
      2. Document compliance with prescribed therapy (see pill counts below)
      3. Last physical therapy visit
      4. Last mental health provider visit
  3. Documentation: Comorbidity
    1. Major Depression (consider PHQ-9)
    2. Anxiety Disorder (consider GAD-7)
    3. Sleep disorders
    4. Pregnancy
  4. Monitoring
    1. Urine Drug Screen
    2. Pill Counts
      1. Patient should bring pill bottles to each visit
    3. Reassess DIRE Score
  5. Stopping or tapering Opioid therapy
    1. See indications below
    2. For a compliant patient without drug misuse, but without benefit at higher dose Opioid
      1. Consider supplying patient with short acting agents for breakthrough pain on titration
      2. Consider supplying patient with smaller increment doses of total daily dose
        1. Supply four 15 mg ER in place of each 60 mg ER

VIII. Protocol: Stopping Chronic Opioids

  1. See Opioid Withdrawal
  2. General indications to stop or taper Opioids
    1. DIRE Score falls below 14
    2. Marginal pain control or decreasing function (or lack of improvement with Opioid)
    3. Non-compliance with prescriptions or with self-care
  3. Indications to immediately stop Chronic Opioids
    1. Threatening or aggressive behavior toward clinic staff or provider
    2. Confirmed diversion, prescription forgery, or obtaining Opioids from multiple sources
    3. Confirmed Illicit Drug use (including Marijuana)
  4. Indications to rapidly taper Chronic Opioids (10-20% weekly)
    1. Repeated early refill requests despite adequate titration of long-acting Opioids
    2. Intoxication or serious adverse effects (e.g. Altered Level of Consciousness)
    3. Opioid-induced hyperalgesia
    4. Broken Controlled Substance Agreement
  5. Indications to gradually taper Chronic Opioids (5-10% every 1-2 weeks)
    1. Morphine equivalent dose >100 mg/day without clear improvement in pain or function
    2. Persistent significant adverse effects despite Opioid rotation
    3. Functional goals not met
      1. Less than 30% improvement in daily activities or pain severity from time of starting Opioids
      2. Less than 30% improvement in daily activities or pain severity from time of last increase in dose
  6. Anticipatory Guidance (what to expect with withdrawal)
    1. See Opioid Withdrawal
    2. Opioid Withdrawal is uncomfortable, but not life threatening (unlike Alcohol and Benzodiazepines)

X. References

  1. (2015) Presc Lett 22(12):68
  2. (2014) Presc Lett 21(12): 67
  3. Sokolove (2001) CMEA Medicine Lecture, San Diego
  4. Lembke (2016) Am Fam Physician 93(12): 982-90 [PubMed]
  5. Berland (2012) Am Fam Physician 86(3): 252-8 [PubMed]

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