This document discusses strategies for maximizing patient safety with opioid prescribing. It notes the rise in opioid overdose deaths and reviews evidence on opioids for chronic pain. It emphasizes the importance of thorough screening, assessing non-opioid options first, using risk tools, random urine drug testing, opioid agreements, choosing appropriate opioids, monitoring for effectiveness and aberrant behaviors, protocols for inheriting patients or tapering opioids, and treating withdrawal symptoms. The overall message is that proper screening, informed consent, monitoring, and multidisciplinary care can help optimize safety when opioids are prescribed for pain.

1. Opioids:
Maximizing Patient Safety
Alberto Rivera Sanchez MD
Diplomate of the American Board of Pain Medicine
Fellow of the American Academy of PM&R
Diplomate of the American Board of Disability Analysts

2. Disclosure
 No drug or medical device company has a financial
interest in this lecture.
“I wish they did, but they don’t.”

3. CDC: Injury and Prevention Control:
Prescription drug overdose. April 2015
 16,235 deaths related to opioid use in 2013
 300% increase in opioid sales

4. Evidence Based Medicine for Opioids
“Are they backed up by evidence?”
 Furlan et al 2006:
 Meta analysis of 41 RCT’s
 Opioids are more effective than placebo for pain and
functional outcomes for nociceptive pain, neuropathic pain
and fibromyalgia
 No study was longer than 3 months
 Most were sponsored by drug companies
 Cochrane Review 2010
 The authors concluded that the evidence supporting
opioids for chronic pain was weak

5. Screening for Opioid Use
“There is a method to our madness”
 Like in marriage subject selection is the key
 Select the patient after thorough history and physical

6. Risk of Opioids
Short Term:
 Nausea
 Vomiting
 Constipation
 Drowsiness
 Respiratory depression
Long Term:
 Tolerance
 Dependence
 Addiction
 Hyperalgesia
 Hormonal imbalances
 Hypogonadism
 OP, Depression, Cognitive
Impairment

7. How to maximize safety
 Assess non opioid Tx:
 Delay opioid Tx
 Adequate W/U
 Trials of non-opioid
Manchikanti. Pain physician 2012
 Opioid Risk Tool
 It is recommended that these
tools are used
 Limited evidence in predicting
addiction risk
J. Pain 2006
Pain physician 2012
 History and PE

8. UDT Urine drug testing
 Must be random
 1st do immunoassay
 Test for opioids, BDZ’s,
Barb’s, Cocaine,
Amphetamines, and THC
 Confirm with gas
chromatography

9. Opioid agreements should talk about
 Medication and drug
prescribed
 Goals of therapy
 Potential adverse effects
 Risk of addiction
 Provider may D/C opioids if
risk outweigh benefit
 Someone stole my
prescription
 2 attempts with law
enforcement report
PM&R Journal 2015

10. What opioid to use???
 No opioid has proven to be a
superior option when
starting opioid therapy
 Most common 1st step:
 Hydrocodone
 Oxycodone
 Morphine
Kirpalani 2015
 Tramadol
 MOR like effects
 Serotonin/NE like reuptake
inhibitor
 Some guidelines:
 Most guidelines start short
acting at low doses
 Then convert to long acting
for higher doses
 Long acting and short acting
have similar efficacy
Manchikanti 2012, Chou 2009, VA
2010

11. According to the DEA
 Schedule 2:
 Must be hand written
 Secure prescription paper
 Tamper proof
 Schedule 3-5:
 May be submitted orally, in
writing or fax
 DEA has permitted e-scripts
but for Schedule 2 a
written copy is still needed
Kirpalani 2015

12. Monitoring effectiveness of opioid Tx
 “Keep your enemies closer”
• Monitor high risk patients
closely
• Frequency of visits is not
clearly defined (Chou 2009)
• 5 A’s of monitoring:
• Analgesia
• Adverse Effects
• ADL’s
• Aberrant behaviors
• Affect

13. Aberrant Behaviors (PM&R 2015):
 Self dose escalation
 Frequent visits for medication refills
 Pain medication form multiple provider
 Alcohol or illicit drug abuse
 Unexpected + or – results
 Lost or stolen prescriptions
 Evidence of diversion

14. Inheriting a patient
• Use the 5 A’s
• Do risks outweigh the benefits?
• Evaluate for aberrant behaviors
• Unstable psychological disease?
• If you do not agree, do “Tapering”

15. Tapering Off Opioids
 High dose patients (>200MED morphine) may tolerate taper
rates until reaching 100 MED
 At 100 MED or less they will start having greater symptoms of
side effects
 Most guidelines recommend a slow taper of 10% per week
 Fast taper is 20-50% every few days
Manchikanti 2012
Kirpalani 2015

16. Withdrawal Symptom Treatment
 Clonidine .1-.2mg BID or .1 to .2mg patch/24hr
 Loperamide
 TCA’s (amitriptyline, nortriptilyne) for irritability, sleep
disturbance and neuropathic pain
 Gabapentin for neuropathic pain
 W/D symptoms may last up to 6 months
Manchikanti 2012
California Guidelines for Prescribing Controlled Substances for Pain Nov 2014
Washington Dc VA 2010

17. Conclusion for safe opioid
prescribing
 Proper screening
 History and PE
 Addiction risk
 Psych Eval.
 UDT
 PDMP
 Have functional goals
 Measure risks
 Consider addiction medicine referral