Neurologists suggest steps for prescribing opioids for chronic pain

The American Academy of Neurology issued a position paper outlining steps that can help physicians who prescribe chronic opioid analgesic therapy (COAT) for chronic noncancer pain (CNCP).

The position paper begins by stating that, since health policies changed in the late 1990s, more than 100,000 people have died, directly or indirectly, from prescribed opioids in the U.S., more than from firearms and motor vehicle accidents in the high-risk group of those ages 35 to 54. The position paper appeared free online Sept. 30 at Neurology.

Recommendations for improving effective and safe use of opioids and reducing the likelihood of severe adverse and overdose events with COAT include the following:

• Track pain and function at every visit using a brief, validated instrument.
• Document the daily morphine equivalent doses (MEDs) in milligrams per day from all sources of opioids at every visit.
• Access state Prescription Drug Monitoring Program (PDMP) data when first prescribing opioids, particularly if during an ED visit; when deciding whether to institute COAT; and again when monitoring COAT, with a frequency according to risk of abuse.
• Screen for past and current substance abuse and for severe depression, anxiety, and posttraumatic stress disorder before starting COAT.
• Use random urine drug screening before starting COAT and periodically while monitoring, with a frequency according to risk.
• Use a patient treatment agreement, when starting COAT and annually thereafter, that adequately addresses the risks of COAT and the responsibilities of the patient.
• Avoid escalating doses above 80 to 120 mg/d MED unless there is a sustained, meaningful improvement in pain and function, and only after consulting a pain management specialist.

COAT patients who have been on doses greater than 120 mg/d MED for at least 90 days can be considered separately, the position paper recommended, pointing out that there are hundreds of thousands of such patients in state Medicaid and workers' compensation programs. One possible approach is to implement a tapering trial if the patient has had a severe adverse event or any overdose, if the patient has evidence of aberrant behavior, or if the patient asks to taper. Prudent tapering policies should also be implemented after hospitalization, particularly in patients who were on COAT at the time of admission. A plan to address transitions back to outpatient care, including a tapering plan, should be addressed preoperatively in nonurgent cases.

“It seems likely that, in the long run, the use of opioids chronically for most routine conditions, such as chronic low back pain, chronic headaches, or fibromyalgia, will not prove to be worth the risk,” the paper stated. “However, even for more severe conditions, such as destructive rheumatoid arthritis, sickle-cell disease, severe collagen disease, or severe neuropathic pain, prescribers need specific guidance on dosing, publicly available brief tools to effectively screen patients for risk, and guidance on how to monitor patients for early signs of severe adverse events, misuse, or opioid use disorder.”