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Opioid Management In Today's Climate

Last in a series of articles about pain management issues and techniques.

By Calvin Chiang, MD

My last article (now online at www.rochestergeneral.org/physican-connection/COT) explored the risks and precautions associated with chronic opioid therapy, or COT. Amid the undeniable risks of opioid abuse, DOH and DEA agents ask only that physicians take appropriate precautionary measures, not to stop prescribing altogether. Logically, practitioners will likely approach this issue in ways that reflect their feelings about COT. Some will choose to not prescribe any opioids whatsoever – a straightforward and perhaps even appropriate solution. However, without some avenue for access (e.g., referrals) some patients may be unduly harmed or denied care.

For the majority of practitioners who will continue prescribing for select patients, consider that any COT initiation or maintenance should include certain key components. First, a thorough pre-COT assessment is required from a medical and legal perspective: Appropriate pain conditions should be identified, and goals of therapy should be established. Functionality and quality of life should be assessed. COT should not be initiated for the purpose of causing functionality; there is almost no evidence-based medicine to suggest this occurs. For patients already on COT, continuation is directly proportional to functionality and lack of complications.

An initial assessment should also include a review of the likelihoods of misuse, diversion, addiction and medical complications. Database searches for felony arrests or other criminal activity should be performed, and will apparently be a prerequisite for writing prescriptions under I-STOP. Screenings should provide insight as to the likelihood of future misuse. ORT and DIRE tests are accessible and easily performed tests that combine simplicity with validity. An initial urine toxicology screen should be obtained; an immunoassay-based screen such as the NIDA-5 is common, but does not provide the quality of evidence necessary for use in monitoring long-term opioid use. Blood tests are not recommended, as some patients may attempt to hide illicit drug use by requesting blood instead of urine tests.

The ultimate decision to start therapy should combine these factors, and provide the patient with clear understanding that ineffective therapy will be stopped. Generally speaking, many pain organizations recommend low dose therapy at a max of 120 morphine equivalent doses a day.

Everyone’s best interests are represented by an “opioid contract,” a treatment agreement that outlines COT risks and benefits, and unequivocally states reasons why treatment could be discontinued, including lack of benefit, noncompliance, and suggestions of diversion. Also, at least every three months COT patients must be reassessed to monitor side effects, urine toxicology and general functionality, as well as to review the safe use and safe keeping of opioid medications.

The RGHS Center for Pain Management is always available to assist PCPs in their handling of COT cases, including seeing patients directly and helping to determine if a patient’s condition is “right” for COT. Patients may be referred directly to the Center, although our team does not routinely take over prescribing, and not at first appointment. For more information, please contact me at calvin.chiang@rochestergeneral.org.

Dr. Chiang is Medical Director of the RGHS Center for Pain Management.