Chronic Narcotic Guideline

1. See Also
   1. Chronic Pain
   2. Chronic Pain Management
   3. Somatization
   4. DIRE Score
   5. Opioid Risk Tool
2. Contraindications (Relative for Chronic Pain)
   1. Substance Abuse (especially Narcotic Abuse)
   2. Severe character pathology or Personality Disorder
   3. Chaotic social environment
3. Guidelines: Chronic Opioid Use Guidelines in Non-Cancer Chronic Pain
   1. Observe for Narcotic Seeking Behavior
   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
   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 Narcotics to long-acting Narcotics
      1. Use long-acting Narcotics around the clock
      2. Use short-acting Narcotics for breakthrough pain
   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
4. Protocol: Initial Assessment for non-Cancer Pain Chronic Narcotic therapy
   1. Select appropriate patients for Chronic Opioids
      1. See DIRE Score
   2. Complete prerequisites at initial visit
      1. Controlled Medication Agreement (Narcotic Contract)
      2. Urine Drug Screen
   3. 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
   4. Review Chronic Pain Flare Management
      1. Flares are same pain type and same location with an increase in intensity
5. 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. Indications to stop Opioid therapy
      1. DIRE Score falls below 14
      2. Marginal pain control or decreasing function
      3. Non-compliance with prescriptions or with self-care
6. Protocol: Stopping Chronic Narcotics
   1. See Opioid Withdrawal
7. References
   1. Sokolove (2001) CMEA Medicine Lecture, San Diego