Safely Prescribing Opioids in Practice

1. Safely Prescribing Opioids in Practice
Foundation for Medical Excellence Pain
Conference-Panel
Feb 19, 2015
Gary M. Franklin, MD, MPH
Research Professor
Departments of Environmental Health,
Neurology, and Health Services
University of Washington
Medical Director
Washington State Department of
Labor and Industries

2. Overarching things to consider
• New patients vs “legacy” patients
• New patients
– Avoid use of opioids in conditions for which the
evidence base for use is very weak
• Avoid opioids in patients with non-specific musculoskeletal
pain, headaches, and fibromyalgia
• For acute use in more severe pain or after minor surgical
procedures, use alternatives to opioids or limit opioid use to
just a few days of short-acting opioids (eg, after wisdom
tooth extraction)
• Risk assessment and clear decision whether or not to
embark on chronic opioid use

3. Overarching things to consider
• When to avoid chronic opioid use
– Current substance abuse (+ cannabis use disorder,
DSM-V)
– No clinically meaningful improvement (30%) in
pain AND function during acute/subacute use
– Concomitant use of benzodiazepines, muscle
relaxants (esp carisoprodol-meprobamate)

4. Clinically meaningful improvement
• At least 30% improvement, function>pain measures after 3
months of opioid use
• Brief instrument should be applied at every prescribing visit
• Use only validated instruments to measure clinically
meaningful improvement in function and pain. The
following tools have been validated and are easy ways to
track function and pain:
a. PEG – A 3-item tool to assess Pain intensity,
interference with Enjoyment of life, and interference with
General activity.
b. Graded Chronic Pain Scale – A 2-item tool to assess
pain intensity and pain interference.

5. Overarching things to consider
• Legacy patients (already on chronic opioids)
– Apply criteria as to whether tapering is indicated
– 100% of patients on opioids chronically are
dependent-they will experience withdrawal
– Opioid use disorder (addiction) may be present
even in the absence of aberrant behavior by DSM-
5 criteria-TALK TO THE FAMILY

6. When to Access Addiction Treatment
• Assess for opioid use disorder or refer for an assessment if a
patient demonstrates aberrant behavior
• Refer patient to an addiction disorder specialist. If that cannot
be done, consult directly with a specialist to identify a
treatment plan
– Combination of medication and behavioral therapies has been found
to be most successful
– Medication assisted treatment with either buprenorphine (office-
based) or methadone (federally licensed opioid treatment program)
Slide 6

7. What can prescriber do to more safely and
effectively use opioids for chronic pain?
• Opioids not first line Rx for most routine conditions
• Use both pharm and non-pharm alternatives
• IF you are using opioids chronically:
• Opioid treatment agreement
• Screen for prior or current substance abuse/misuse (alcohol,
illicit drugs, heavy tobacco use)
• Screen for depression
• Prudent use of random urine drug screening (diversion, non-
prescribed drugs)
• Do not use concomitant sedative-hypnotics or benzodiazepines
• Track pain and function to recognize tolerance
• Seek help if morphine equivalent dose (MED) reaches 80
mg/day MED (eg, Ohio) and pain and function have not
substantially improved
• Use your state Prescription Drug Program to track all
sources of conrolled substances!
Slide 7

8. Case definition for when to taper
• Patient requests opioid taper.
• Patient is maintained on opioids for at least 3 months, and there is no
sustained clinically meaningful improvement in function (CMIF), as
measured by validated instruments (Appendix B: Validated Tools for
Screening and Assessment)
• Patient’s risk from continued treatment outweighs the benefit (e.g.
decreased function and increased risk for opioid-related toxicity from
concurrent drug therapy or comorbid medical conditions)
• Patient has experienced a severe adverse outcome or overdose event
• Patient has a substance use disorder (except tobacco)
• Use of opioids is not in compliance with pain management rules or
consistent with guidelines
• Patient exhibits aberrant behaviors (Table 9)
http://www.agencymeddirectors.wa.gov/guidelines.asp
Berna et al, Mayo Clin Proc 2015; 90: 828-42

9. Non-Pharmacologic Alternatives
• Do NOT pursue diagnostic tests unless risk factors or specific
reasons are identifie
• Use interventions such as listening, providing reassurance, and
involving the patient in care
• Recommend graded exercise, cognitive behavioral therapy,
mindfulness based stress reduction (MBSR), various forms of
meditation and yoga or spinal manipulation in patients with back
pain
• Address sleep disturbances, BUT, the greatest risk lies in co-
prescribing benzodiazepines and sedative/hypnotics with opioids,
even at lower doses of opioids
• Refer patient to a multidisciplinary rehabilitation program if s/he
has significant, persistent functional impairment due to complex
chronic pain
Slide 9

10. Pharmacologic Alternatives
• Use acetaminophen, NSAIDs or combination for minor to moderate pain
• Consider antidepressants (TCAs/SNRIs) and anticonvulsants for
neuropathic pain, other centralized pain syndromes, or fibromyalgia
• Avoid carisoprodol (SOMA) due to the risk of misuse and abuse. Do NOT
prescribe muscle relaxants beyond a few weeks as they offer little long-
term benefit
• Prescribe melatonin, TCAs, trazodone, or other non-controlled substances
if the patient requires pharmacologic treatment for insomnia
Slide 10

11. Opioid Use in Special Populations
• Cancer survivors – Model pain treatments after chronic non-
cancer pain strategies, rather than palliative therapies
• During pregnancy and neonatal abstinence syndrome –
Counsel women on COT to assess potential risk of
teratogenicity
• Children and adolescents – Avoid opioids in the vast majority
of chronic non-malignant pain problems in children and
adolescents
• Older adults - Initiate opioid therapy at a 25% to 50% lower
dose than that recommended for younger adults
Slide 11

12. For electronic copies of this
presentation, please e-mail Laura
Black
ljl2@uw.edu
For questions or feedback, please
e-mail Gary Franklin
meddir@u.washington.edu
THANK YOU!