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Webinar 3b: Guide to Rational Opioid Prescribing: ...
Webinar 3b: Guide to Rational Opioid Prescribing: Monitoring and Responding to Misuse
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Video Transcription
In follow-up to Dr. Prattken's discussion of the nature of chronic pain and the role of opioids in its management, I'm now going to discuss certain core concepts related to how opioids are misused and abused, and introduce the latest guidelines of the North Carolina Medical Board and the U.S. Centers for Disease Control and Prevention for prescribing opioids for chronic pain. A concern among clinicians who prescribe opioids, as well as other control medications, is that these medications might be misused in a way that might cause harm to the patient or to others. This concern has escalated as the surge in overdose deaths has made this risk more apparent, and it's reflected in the increased attention by regulatory agencies, like the state medical boards, who are increasingly concerned that opioids should be prescribed in a way that limits the chances of their misuse, abuse, or diversion. For example, the North Carolina Medical Board 2014 Guidelines on Prescribing Opioids for Chronic Pain states, When the decision to use an opiate has been made, progress will be carefully monitored for the benefit and harm in terms of the patient's physical, functional, and psychosocial activities. Attention will be focused on adverse events and risks to safety. In the following modules, we will discuss specific strategies to address these risks. But before we do, it's important to have a workable understanding of what we mean by drug abuse, or terms like dependence or addiction, and to have a realistic perspective on their occurrence and associated risks. One reason to pay attention to this is that much of the terminology in this area is either vague, misunderstood, or actually misleading. Many of the expressions used by clinicians, although seemingly descriptive, lack specificity, and in some cases, terms like drug-seeking or doctor-shopping, are not just vague but pejorative or condescending. This confusion can be compounded by the fact that behaviors associated with misuse or abuse, or even addiction, can overlap with a patient's frustrated or misguided attempts to mismanage or manage his or her pain. Behaviors may be interpreted differently depending on the practitioner's personal experiences and perspective, and clinicians often remember difficult or problematic patients more clearly than non-problematic ones, generating a bias in perspective and perception of regulatory or legal risk that can exaggerate this bias. To the point that the clinician avoids using opioids entirely, he or she becomes opioid-phobic or overly reacts to behaviors labeled as non-compliant or manipulative. So let's think about how we can categorize the range of medication-related behaviors that may be seen as aberrant, that is, using the medication, in this case, opioid analgesics, in ways other than intended by the prescribing clinician. One category of clearly aberrant behavior is to obtain or use them when there's no genuine therapeutic indication, that is, no true medical purpose for their use. Rather they're being used recreationally or being obtained solely for the purpose of diversion, that is, for resale. Another large category of behaviors would be those related to a medical purpose but using the medications other than as prescribed, often in a self-directed way and sometimes without good judgment or without recognition of risk. One example could be overusing a medication, that is, using it in amounts or frequency greater than indicated by the prescription, but doing so to try to obtain relief from poorly treated pain. Another example would be using an opioid analgesic prescribed for physical pain for relief from emotional distress, so-called chemical coping, or to help with sleep, or for some to paradoxically activate or provide energy. The final category in this triumvirate of aberrant behaviors would be those who seek and use opioids for the maintenance of an undiagnosed opioid addiction, generally unrecognized and undiagnosed, not only by the prescribing clinician but also often by the individuals themselves. It's worth talking about this concept of addiction a bit more because for many patients, as well as some clinicians, there's a confusing overlap between the terms dependence and addiction, a confusion that can result in distress and difficulty for the patient and the clinician. First off, it's important to recognize that dependence, in the sense of physical dependence, should be thought of as a distinct clinical phenomenon, sometimes overlapping with addiction but often entirely independent of it. An individual with chronic pain prescribed opioids on a regular basis and using them appropriately for pain and with improved quality of life as a result would be physically dependent on them, that is, at risk for a withdrawal syndrome if the medication were to be stopped or dramatically decreased. But that doesn't mean that they are necessarily addicted. Emotional dependence is a phrase sometimes used to describe the strong emotional attachment that an individual may develop around the use of some medications like opioids or benzodiazepines, either because of the reward value of the medication, getting high, feeling relaxed, avoiding pain, or the anxiety of anticipating going without the medication. Although this can be seen in an addictive attachment to a drug, it's also easy to imagine how it can also develop in someone who uses a medication appropriately but relies upon it to avoid debilitating pain. Tolerance, that is, needing an increased dose to get a similar effect, is also sometimes seen in those taking opioids regularly over time but does not necessarily indicate misuse, although it can present a challenge for clinicians at times when a patient presents requesting ever-increasing doses of opioid medication. Is this physiological tolerance or someone seeking additional reward response from the medication? Finally, addiction, on the other hand, although it can be associated with tolerance and dependence, refers to a set of behaviors that demonstrate a lack of control or how the medications are used and a persistent and often escalating pattern of impairment and problems related to that out-of-control use. Given the overlap in some of these symptoms or patterns of behavior, a clinician might have a difficult time sorting between someone physically and possibly emotionally dependent on their prescribed opioid and trying to use them as prescribed and separating that from another patient whose use is causing serious impairment consistent with addiction. As a result, some react to this conundrum by seeing everyone on chronic opioid therapy as, quote, a little bit addicted. But this is misleading and potentially pejorative perspective and is one of the reasons that the term addiction, although still used by the general public and many clinicians, is not a currently accepted diagnostic term. I would emphasize that sorting this out clinically relies on getting curious and taking the time needed to determine if the use of the medication is improving the individual quality of life or causing impairment and deterioration in function. Are the behaviors the result of poor judgment, lack of adequate pain treatment, untreated emotional comorbidities, all factors that can be addressed by modifying treatment? Or do they represent a persistent inability to manage and use the medication, which means it can no longer be safely prescribed? A reassuring perspective on this dilemma is that when large cohorts of individuals being prescribed opioids for chronic pain are looked at carefully and non-judgmentally, most reviews of medication-related behaviors are consistent with this diagram shown here, representing relative frequencies of appropriate use versus misuse and addiction. Specific percentages vary depending on criteria and demographics, but the relative proportions are fairly consistent. The majority, often the large majority of these patients, use their medications appropriately and as prescribed. A small minority, generally a very small minority, demonstrate actual addiction, that is, demonstrate a persistent or recurrent pattern of overuse and serious problematic use in such a way that they meet clinical criteria for addiction. So that's the good news. Those with actual addiction are really a small minority, but in many studies there's an intermediate group, sometimes a significant percentage, who misuse their opioid medications in a way that puts them or others at risk. However, there are a number of tools or clinical strategies that are thought to be useful in preventing, mitigating, or responding to misuse, abuse, or even addictive use. One, appropriate risk stratification and modification of treatment planning based on relative risk. Two, judicious ongoing monitoring when prescribing opioids or other medication with abuse potential. Three, intervening, that is, investigating and modifying the treatment plan when misuse is suspected or identified. It's worth noting that most of these strategies are based on expert or consensus opinion. They have face validity, but little outcome data at this time to support their use. However, they have become generally accepted and are currently expected as part of the evolving standard of care related to the use of opioids. At the national level in 2013, the CDC, after an extensive process of review and garnering of expert opinion, published their guidelines on the use of opioids in the setting of pain management. In addition, most state medical boards have now published their own guidelines or, as in the case of the North Carolina Medical Board, have referred practitioners to the CDC guidelines. I recommend that everyone take the time to read through these recommendations, which are easily available online. You'll find a brief description of the recommended guidelines as well as the background data and rationale if you want to delve further. Changes in terms of emphasis or specific recommendations include discouragement of use of opioids as first-line treatment, discouragement of excessively high dosing, encouragement of a therapeutic trial approach, more attention to risk assessment, monitoring, and use of referral, and routine use of prescription monitoring programs, such as the North Carolina CSRS, as well as urine and other drug screening as useful clinical tools, both for initial treatment planning and ongoing management and monitoring. Interventions for misuse or abuse, including use of addiction treatment referrals when needed, are also given additional emphasis in these guidelines. How these recommendations play out may vary in different specialties or clinical settings, but the general concepts will apply across specialties, so this training, including the modules that will follow, will reinforce these recommendations. In this next role play, we'll take a look at universal precautions. Well, Alicia, you know, we've been working together for several months now on trying to get you relief from your pain, and I think we've had some success. You've been very active in participating in the physical therapy. I think you've had some improvement, but what I'm hearing from you is you still have a significant amount of pain, and it's pain that interferes with your ability to function and get on with things. Yes. So I think it really does make sense for us to consider a trial of opioid therapy, something like oxycodone or something similar, to see if that can get you a better level of function and some better pain relief. I know when we prescribe oxycodone in this practice, we routinely get a urine drug screen as part of our evaluation before doing that, so I'll have the nurse come in, she'll ask you for a urine sample, we'll look at that, and then we'll talk about the results and move forward. Sure. That's really necessary. None of my other doctors have done this to me. Well, I think it is necessary, and it doesn't surprise me a lot that the other docs haven't necessarily done it. I mean, this is something that's become increasingly the recommendation, and so now groups like the North Carolina Medical Board and a lot of the authorities recommend that if you're going to use opioids, you do routine drug screening both initially and as part of the routine follow-up, so you can expect it as part of the follow-up as well, and it's one of the ways that we can kind of keep things safe. Make sense? Okay. It just seems like you don't trust me. Well, you know, I can see where you'd react to it that way, but it's really not trust so much as safety. Opioids can interact with a lot of other medicines, they can interact with alcohol and other recreational drugs, and it's really important for you to know that and for me to know that, and so by doing the drug screen, it's one of the ways we can keep things safe, which means that if these medicines are working for you, we can continue to prescribe them. Make sense now? Okay. Maybe as long as everybody's getting it. Yeah. Absolutely. It's not something specifically about you. It's part of our routine. Okay. Good. All right. We all know that even after due diligence with screening and risk stratification and reasonable initial treatment planning, that aberrant medication-related behaviors will occur and with proper monitoring will be noticed. It's of course important and expected that the clinician will respond and intervene with these behaviors, and we will deal with this in more detail later, but suffice it to say at this point that the intervention needs to fit the level of risk and concern. For this, further evaluation, further clinical curiosity is needed before taking action. Clearly, when safety is a prominent concern, it may be necessary to stop prescribing the opioid medication or refer for referral management and addiction treatment, but sometimes it may allow safely continuing the medication but adapting the treatment plan, such as closer monitoring or referral or consultation. I will close this section by referencing the clinical algorithm that will be used as we proceed through the following modules. This basic treatment algorithm is similar to the approach commonly used across specialties and with any chronic medical condition. Assess, initiate treatment, monitor, adapt treatment as needed. In this particular clinical area of prescribing opioids for chronic pain, attention will be focused on adequate assessment for risk stratification, indications and contraindications for safe opioid use, informed consent, treatment agreements and establishing realistic goals for an opioid trial, time-efficient monitoring to maintain safety and effectiveness, and adapting treatment, intervening when needed and when and how to stop prescribing opioids. Thank you for your attention and good luck in working through the remainder of the training.
Video Summary
The video discusses the misuse and abuse of opioids and introduces the guidelines of the North Carolina Medical Board and the U.S. Centers for Disease Control and Prevention for prescribing opioids for chronic pain. It explores the confusion and overlap between terms like drug abuse, dependence, and addiction. It categorizes different medication-related behaviors that may be seen as aberrant, such as obtaining or using opioids without a therapeutic indication, overusing medication, or using opioids for purposes other than pain relief. The video emphasizes the importance of careful assessment, monitoring, and intervention when misuse is suspected or identified. The recommendations for preventing misuse and responding to it include risk stratification, ongoing monitoring, and appropriate interventions. It also discusses the use of drug screening and monitoring programs. The video concludes with a discussion on how to adapt the treatment plan and when to stop prescribing opioids. The video provides helpful information for clinicians on how to address the risks associated with opioid use and ensure patient safety.
Keywords
opioids
misuse
abuse
guidelines
chronic pain
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Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 and grant no. 1H79TI085588 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
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