This month’s case focused on talking to patients about opioid prescriptions, given the high risk for misuse and overdose with this class of analgesic. Specifically, we asked the community to consider how to determine if a patient is a good candidate for opioid analgesia, what to do if there is a concern about opioid misuse, and how provide appropriate care for pain and potential addiction. There was a great amount of commentary on the blog as well as twitter which was amalgamated in this second summary. This week’s wrap-up also includes two expert responses to the case, and some resources you can implement in your own practice.

Responses to Case 1.02

Dr. Lauren Whiteside

Expert 1

Lauren Whiteside, MD, MS

Dr. Whiteside is an Acting Instructor of emergency medicine at the University of Washington. She completed a research fellowship at the National Institute on Alcohol Abuse and Alcoholism (NIAAA T32), Substance Abuse Division, and has a continued research interest in opioid abuse.

Dr. Maryann Mazer-Amirshahi

Expert 2

Maryann Mazer-Amirshahi, PharmD, MD, MPH

Dr. Mazer-Amirshahi is an emergency medicine physician and medical toxicologist at MedStar Washington Hospital Center. She has conducted extensive research on prescription drug abuse, medication reconciliation, patient adherence, and drug shortages.

Prescription Opioid Misuse Background

In 2012, approximately 6.8 million Americans reported non-medical use of prescription drugs in the past month, which exceeds the number of Americans using cocaine, heroin, hallucinogens, and inhalants combined. In 2007 there were more injury deaths due to drug overdose than motor vehicle collisions, with prescription opioids being the most commonly implicated substance. According to the Centers for Disease Control, for every prescription opioid overdose death there are 32 Emergency Department visits for non-medical prescription opioid use, 130 people who are opioid dependent, and 825 people that use prescription opioids non-medically. Although there is lack of consensus in the literature, prescription opioid misuse (POM) is a term used to encompass the heterogeneous group of behaviors that includes non-medical use (i.e., without a prescription) and medical misuse (i.e., with a prescription but in a manner not intended by the prescriber) of prescription opioids. POM can lead to further adverse health outcomes including opioid dependence and addiction, injection drug use, overdose, and death.

How to make a decision regarding opioid prescription

Identifying patients with POM can be challenging in an ED setting as patients are frequently seeking care for a variety of conditions causing acute pain.  There are many historical factors and health services factors that can indicate a patient is at risk for POM including previous overdose, history of opioid dependence or abuse, multiple prescriptions from a varied number of providers, co-occurring prescriptions for opioids and sedatives, and multiple ED visits. Patients with POM are complex and have heterogeneous medical presentations, fragmented healthcare delivery, associated substance use disorders, comorbid mental illness, chronic pain, and other chronic medical problems. Additionally, motivations for POM are variable and include coping with physical pain, anxiety, and sleep.

For Mr. Wilson, an opioid prescription is not indicated for his pain. He has many comorbidities and risk factors for POM and unintentional overdose including depression, alcohol use, fragmented health care, and multiple recent prescriptions from a variety of providers. Using a statewide Prescription Drug Monitoring Program (PDMP) is extremely important and highly valuable in this case. Some states including Washington have additional health information exchange databases. The Emergency Department Information Exchange (EDIE) is a system that is used by nearly all hospitals in the state of Washington. EDIE collects patient information at the registration point from participating facilities, aggregates the data, and then proactively alerts ED care providers when patients with patterns of high utilization present for care. Consulting published guidelines for opioid prescribing from the ED is important and, while guidelines should not be used as protocols, many published guidelines would advocate against opioids for this patient.  The Washington College of Emergency Physicians (WACEP) in coordination with other statewide agencies authored Emergency Department opioid prescribing guidelines in 2010 that specifically include having one physician provide opioids for chronic pain. It is known that medical use of opioids can lead to POM, and Mr. Wilson’s history of an injury years ago probably resulted in a legitimate prescription for opioids (i.e., medical use of opioids). The combination of known POM and overdose risk factors, PDMP results and health information exchange results, as well as published guidelines inform my decision regarding opioid prescription for every patient I see in the ED.

What Do I Say?

At this point, it is time to talk to the patient regarding the decision not to use opioid therapy for pain control. While addressing concerns about substance use and addiction are important, many patients with POM do not identify as having a substance abuse problem. Therefore, I frame my initial discussion around medication safety as opposed to addiction and substance use. I usually begin by acknowledging the patient’s pain and concerns regarding pain management. Again, as many of these patients have medical comorbidities, it is important to remember that these patients are having real pain. Next, I usually update the patient with what I know regarding PDMP and health information exchange results. Then I discuss the patient’s comorbidities and express my concern about overdose risk. Lastly, I tell the patient what I am willing to do to treat his pain, but inform him that I am not going to provide a prescription for opioids. This is usually framed in a way so the patient understands I am practicing within guidelines provided by my hospital and state.

Specifically, I say:

“Mr. Wilson, I know you are having severe back pain, and I am sorry you are so uncomfortable.  I just received some statewide records that show you had several recent ED visits and received a prescription for oxycodone 11 days ago and again 3 days ago. I know you are having pain, but it is important for you to get all the pain medications you need from one prescriber. Additionally, with your alcohol use, I worry that the mix of alcohol and opioid pain relievers puts you at risk for an accidental overdose. I am willing to prescribe an increased dose of NSAID’s, help get you plugged in with physical therapy, and most importantly get you a primary care provider so you can establish care with someone that can treat your back pain and other health problems long term. However, I will not be providing you with a prescription for oxycodone as this hospital uses state-wide guidelines that advise against prescribing opioids from the ED for chronic pain such as the back pain that brings you to the ED today.”

At this point you can also assess receptivity for continued discussion about opioids in general if the patient is willing to engage in this type of questioning. Using open-ended questions you can say:

“Would it be okay if we talk more about your prescription opioid use? Tell me about a typical day for you and how you normally take your medications.”

Again, framing this discussion around medication safety will provide insight about motivations for use. For instance, if someone increases his prescription opioid use at night, this may indicate he has sleep disturbance and you can talk more about alternative ways to improve sleep.

Overall, it is important to remember that patients with POM have a large number of comorbidities and present with real pain. If you are considering treatment with opioids, you need to understand individual patient risk for POM and overdose, but using statewide databases such as the PDMP and adherence to published guidelines is important. This approach will also allow for a discussion that feels less adversarial and more objective. The overwhelming majority of these patients do not identify as having a substance use problem, opioid dependence, or addiction. Discussing pain management from the perspective of safety will keep the patient engaged and allow an opportunity to bring up issues surrounding overdose risk and motivations for misuse if the patient is willing to talk about these topics. If a patient recognizes his pattern of opioid use to be problematic and consistent with misuse then a referral for treatment or to addiction medicine if this is possible in your practice setting is important.

Does the patient have an indication for an opioid?

Evidence supporting the use of opioid analgesics for chronic non-cancer pain is limited. This is true of conditions such as headaches, fibromyalgia, neuropathic pain, and as in this case, low back pain. In these situations, use of opioid analgesics is generally discouraged and recommended only when multiple other therapies have failed. There is evidence to endorse the use of opioid analgesics for acute pain; however, the benefits of therapy diminish after a few weeks to months.

When managing patients with chronic pain, optimizing non-opioid therapies is crucial. The aggressive use of non-opioid therapies can forego the need for opioid therapy or may decrease the dose required if opioids are used. In the case of low back pain, there are several alternative therapies that should be considered before opioids are employed or as a therapeutic alternative. Acetaminophen and non-steroidal anti-inflammatory drugs are first line therapies for many painful conditions. If muscle spasm is present, a muscle relaxant can be tried; however, care should be taken to avoid benzodiazepines and carisoprodol because of their abuse potential. Patients with a neuropathic component to their pain may benefit from agents such as gabapentin or tricyclic antidepressants. Corticosteroids can also be of benefit in the management of back pain.

In addition, there are several non-pharmacologic therapies for back pain. Physical therapy, chiropractic therapy, and surgery are potential treatment options. Often, a multi-faceted approach is required to receive adequate pain control. Treatment should be individualized depending on the patient but the point is that there are a lot of options that can be used instead of opioids.

Managing patient’s expectations should be part of any provider encounter. It is important for us as providers to first acknowledge the patient’s pain and assess what they expect from the encounter. Sometimes, patients do not expect an opioid analgesic, but we may prescribe opioids because that is what we think the patient wants. Alternatively, patients may be driven by fear that there is something wrong and want reassurance. We may also need to reset patient expectations because in some cases we will not be able to get their pain to a “zero” and their painful condition may be chronic. If the patient is expecting to be treated with an opioid analgesic, we need to explain the indications for opioid therapy and our rationale behind the course of therapy we are prescribing.

Good prescribing practices

When considering opioid analgesics as part of a patient’s pain management strategy, it is important to perform a risk assessment for abuse. This step can be easily overlooked in a busy emergency department. Commonly encountered risk factors for opioid abuse is a history of substance abuse, prior opioid use, psychiatric comorbidities, and age between 20 and 40 years. These major risk factors can be quickly identified during the history and physical.

When the decision is made to prescribe opioid analgesics to a patient and a risk factor assessment has been performed, consider current best practice guidelines for the prescribing of these medications. Your individual state may also have specific guidelines, which are generally voluntary but strongly recommended. Examples of best prescribing practices include using short-acting opioids, starting at low doses, and avoiding extended-release preparations. Prescribe short (no more than 3 days) courses of therapy and avoid using opioids for exacerbation of chronic pain whenever possible. Concomitant prescribing of benzodiazepines and other central nervous system depressants should be avoided. If available, consult your state’s prescription drug monitoring program to assess for high-risk usage patterns and doctor shopping. Communication and close follow up with a primary care provider should be arranged whenever possible. Patients can also be provided with pain management resources. Providers should have an open discussion with patients about the potential for dependence and addiction associated with these medications.

What do I say?

“Mr. Wilson, I understand this back pain is having a significant impact on your quality of life. I see that you have recently gotten prescriptions for oxycodone, but unfortunately, there is not a lot of evidence that these medications are effective for treating back pain long-term. There is also a chance that you could develop an adverse effect or become dependent on or addicted to medications like oxycodone. At the same time, I want to address your pain.

I think we can get your pain under better control, but it will take a combination of treatments and your pain may not go away completely. I would like you to continue to take the ibuprofen and I will also prescribe a muscle-relaxant and a short course of steroids. I would like you to follow up with your primary doctor within the next week. He may be able to refer you for additional services such as physical therapy that may help your back pain. If that doesn’t work, here is the number for the pain management clinic affiliated with our hospital. Do you have any questions?”

This summary was produced as a qualitative, thematic review of the blog and twitter discussion created by the Ed in the ED community. All community commentary was aggregated, and the following common themes were identified in a majority of responses.

Check your bias

While this case presents one example of a fictitious patient, it is important to remember that anyone can suffer from opioid dependence or abuse; unchecked personal bias often leads to diagnostic errors. Although there are some established risk factors for opioid misuse, your approach to identifying, diagnosing, and treating these patients should be with an open mind.

Furthermore, diagnostic anchoring bias may preclude you from discovering more serious pathologies underlying this patient’s presentation to your emergency department. For the patient presented in this case, it is still important to consider diagnoses like epidural abscesses or discitis to ensure they are not overlooked solely because of provider bias.

Finally, it is important to remember that not all patients recognize their use of opioid medications is inappropriate–some may honestly be trying to manage pain they find insufferable. Previous providers may not have fully explained the addictive nature of these analgesics, and you might be the first healthcare provider to help them realize that their pattern of opioid use is abnormal and dangerous. You should not approach the conversation with the mindset that your patient is an addict whom you need to provide with resources, but rather approach the patient as someone who clearly has a reason for using opioid medications that you need to explore together.

Deciding who should get opioids

Identifying which patients are good candidates for opioid analgesia is very difficult, especially in areas of the world without firm opioid prescribing guidelines. If you are practicing in such an area, you may consider using a risk assessment tool such as the Opioid Risk Tool (ORT) and Diagnosis, Intractability, Risk, Efficacy (DIRE) tool found at . While these tools are not perfect and more prospective research needs to be done to demonstrate they predict clinical outcomes, a patient with high scores on these assessments should, at a minimum, increase your concerns about prescribing opioids.

Downloadable PDF’s of these assessment tools can be found by clicking here .

At the very minimum, you ought to consider these key risk factors for opioid abuse:

  1. A family or personal history of substance abuse
  2. Young age
  3. A history of pre-adolescent sexual abuse
  4. A concurrent history of mental illness

Patients with any these characteristics have a significantly higher risk of opioid misuse and are likely better candidates for other analgesia alternatives. This being said, a patient with no risk factors and a low risk assessment score on one of the aforementioned tools may still be a poor candidate for opiate prescription. Only after a comprehensive conversation with your patients about the risks and benefits of these drugs as well as their plans for future pain management can the appropriateness of short course opiate prescription be assessed.

Even still, as many community commentators mentioned, the efficacy of managing chronic pain with opiates is still being being studied; thus future evidence may make this decision much easier.

Be direct and non-confrontational

Once you have made a decision regarding opioid prescription, the overwhelming response from the community was to be direct and non-confrontational about your choice and the reasons for it.

If you are not going to prescribe opiates to a patient, it is important to tell her upfront that you do not believe opioid medications will provide the best relief for her pain and to lay out other options that you will pursue together to get her pain under control: emphasize that you are not abandoning the patient’s need for pain relief, but that you want to work on shared goals for providing safe pain relief. This is a great time to address some of the serious side effects of opioid use, and to ask patients if they have struggled with any of these issues while using opioids in the past. Be honest about the benefits and risks of these medications, especially if the patient is taking sedatives or psychotropic drugs.

With this approach, opening a conversation about addiction concerns shifts the burden away from the patient, and on to the medication–avoiding a potentially encounter-ending confrontation. If the patient is truly misusing opioids, remember your goal is to get him the help he needs to stop. While the decision to follow that plan is ultimately the patient’s, the way you offer help and explore the patient’s thoughts on the topic has a huge impact on the likelihood that he will follow through with the care he needs.

In the case described above, where the patient is known to have received multiple opioid prescriptions recently, the community also advocated open communication about this knowledge. Be upfront with this information, and do not try to bait your patient into being dishonest only so you can confront them with the information from a Prescription Drug Monitoring Program (PDMP). Do not lead your patient to believe this is a punitive conversation.  Instead, you should express a genuine concern that your patient may be at risk for dangerous opioid complications and that his pain is not being effectively managed.

Here is an example, derived from several community suggestions:

“Mr. Wilson, according to the state database records, you have recently received two prescriptions for oxycodone. I am concerned that these medications are not effectively managing your pain in a safe way. The Oxycodone family of drugs is not effective for chronic pain: your body gets used to them and you end up needing higher and higher doses, making you constipated and putting you at risk for serious addicted. Is there a chance you feel dependent on these drugs already?”

Provide the right care

After eliciting your patient’s needs and goals, deciding upon the right care is important. If you have decided to offer opioid analgesia to your patient, consider short term prescriptions lasting less than two weeks to reduce the risk of abuse. You need to Also, plan appropriate follow up with your patient so that they can continue their care within the timeframe of your prescription. You should educate patients that coming to the ED is not a good option for managing chronic pain, and that if they continue to receive care with outpatient follow up they will be more satisfied with their care. Additionally, document this conversation with the patient so that if they do return to the ED for chronic pain management, future providers can inquire as to why the patient deviated from the agreed upon plan. If ultimately you decide to offer non-opioid analgesics to manage your patient’s pain, you should provide the same advice and specifically mention the risks and benefits of whatever medication you are providing.

In the case where your patient is concerned they are opioid dependent, you ought to provide follow up with local drug treatment and detox programs. It is important to keep up to date on all of the specific programs offered for opioid addiction therapy in your area so that you can make recommendations specific to your patients needs. As healthcare providers it is our responsibility to stay abreast of these resources to maximize patients chances of recovery.

Thank you to all of the participants on the blog and Twitter!

Check back soon for a downloadable PDF of the case and responses.