1. The Pains of Chronic Opioid Usage
Spotlight Case
The Pains of Chronic Opioid Usage

2. Source and Credits
This presentation is based on the September 2013 AHRQ WebM&M Spotlight Case
See the full article at
CME credit is available
Commentary by: Laxmaiah Manchikanti, MD, University of Louisville, and Joshua A. Hirsch, MD, Harvard Medical School
Editor, AHRQ WebM&M: Robert Wachter, MD
Spotlight Editor: Bradley A. Sharpe, MD
Managing Editor: Erin Hartman, MS

3. Objectives
At the conclusion of this educational activity, participants should be able to:
Describe the appropriate initial assessment of patients with chronic non-cancer pain
List the most common errors made in prescribing opioids for non-cancer pain
Outline appropriate monitoring for patients prescribed opioids for non-cancer pain
Appreciate the need to risk-stratify patients taking opioids for non-cancer pain

4. Case: Pains of Chronic Opioids
A 42-year-old man with a history of asthma and chronic lower back pain was admitted to the hospital with community-acquired pneumonia and an asthma exacerbation. His primary care physician (PCP) had been prescribing high doses of long-acting morphine (MS Contin), oxycodone, and gabapentin for his low back pain. He was marginally housed and often slept in shelters.

5. Case: Pains of Chronic Opioids (2)
On admission to the hospital, he was treated with nebulizers, antibiotics, and prednisone. Due to some odd behavior and suspicion for substance abuse, a urine toxicology test was sent and results were positive for benzodiazepines, methadone, and opiates. As neither benzodiazepines nor methadone were prescribed medications, the hospitalist confronted the patient who admitted selling his prescribed opiates and buying diazepam and methadone on the street. He stated that these could "control [my] pain better."

6. Background Opioids frequently used in chronic non-cancer pain
In US, enough opioids are prescribed to supply every adult American with 5 mg of hydrocodone 3 times daily for more than 45 days
Opioid prescribing for chronic pain in ambulatory setting doubled from 8% in 1980 to 16% in 2000
Approximately 20% of patients in primary care were longtime opioid users, and nearly 2/3 had received at least one course of opioids
Increasing use is not based on evidence of efficacy or supported by safety data
Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–Guidance. Pain Physician. 2012;15(3 suppl):S67-SS116.
Centers for Disease Control and Prevention. CDC grand rounds: prescription drug overdoses—a U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012;61:
Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs Pain. 2004;109:
Deyo RA, Smith DH, Johnson ES, et al. Opioids for back pain patients: primary care prescribing patterns and use of services. J Am Board Fam Med. 2011;24:
Manchikanti L, Ailinani H, Koyyalagunta D, et al. A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain. Pain Physician. 2011;14:

7. Nonmedical Use of Opioids
How often patients use opioids without a prescription or outside limits of prescription is unclear
It may be as much as 5% to 41% of patients prescribed opioids
The use and abuse of opioids can result in injury and death
Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–Guidance. Pain Physician. 2012;15(3 suppl):S67-SS116.
Manchikanti L, Cash KA, Malla Y, Pampati V, Fellows B. A prospective evaluation of psychotherapeutic and illicit drug use in patients presenting with chronic pain at the time of initial evaluation. Pain Physician. 2013;16:E1-E13.

8. Overdose on Prescription Medications
A Centers for Disease Control and Prevention (CDC) study characterized patients who had overdosed on prescription medications:
Approximately 80% of patients prescribed low doses (defined as <100 mg of morphine equivalent dose/day) accounted for only 20% of all prescription overdoses
The 10% prescribed high doses accounted for an estimated 40% of prescription opioid overdoses
Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–Guidance. Pain Physician. 2012;15(3 suppl):S67-SS116.

9. Errors in Opioid Prescribing
Providers may make multiple errors when prescribing opioids for non-cancer pain
It is useful to classify opioid prescribing errors into four categories:
Inadequate screening for safe and effective opioid use
Inability to monitor adherence
Improper selection of opioids
Insufficient consideration of comorbid conditions

10. Prescribing in This Case
For this patient, there may have been inadequate screening for safe use, potentially improper selection of opioids, and possibly insufficient consideration of his asthma
The patient was also receiving both long-acting and short-acting opioids
This can be a setup for fatalities and deaths, particularly when comorbid factors are considered
Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–Guidance. Pain Physician. 2012;15(3 suppl):S67-SS116.

11. Case: Pains of Chronic Opioids (3)
Given complexity of the pain regimen and the drug diversion, the hospital's pain service was consulted. They changed the patient's medications to methadone, hydromorphone, clonazepam, and venlafaxine. The morphine and oxycodone were discontinued. With this regimen, the patient had reasonable pain relief at discharge. He was discharged with a prescription for a 2-week supply of medications and had a follow-up appointment with his PCP 10 days later. As it was a weekend, the discharging hospitalist was not able to speak directly with the PCP but sent her an with the medication changes.

12. Case: Pains of Chronic Opioids (4)
Five days after discharge, the patient was found unconscious at a subway station and pronounced dead at a local hospital following unsuccessful resuscitation. Based on the clinical presentation, the cause of death was likely from unintentional opiate/benzodiazepine overdose. In reviewing his medications, the patient had refilled his MS Contin and oxycodone one day prior to admission. Unfortunately, this information was not available to the hospitalist, and the patient stated that he had not recently refilled his opiates. The patient filled the new prescriptions for methadone, hydromorphone, and clonazepam on the day of discharge.

13. Reflections on Case
Unclear from case details whether patient's unexpected death could have been prevented
This scenario acts as a powerful reminder of the risks of opioid prescribing
It would seem much can be done to prevent such events in the future

14. Preventing Errors in Opioid Prescribing
All providers should follow appropriate guidelines to provide proper prescriptions
Enhancing and updating clinical teaching and training is crucial for all providers, especially those involved in pain management
A more comprehensive and contemporary curriculum for prescribers seems warranted

15. Best Practices for Preventing Errors
A 10-step algorithm can be used to optimally prescribe opioids for non-cancer pain
The algorithm describes the following steps:
Diagnosis
Determination of medical necessity
Establishment of treatment goals
Informed consent
Adherence monitoring
Addressing adverse effects
Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–Guidance. Pain Physician. 2012;15(3 suppl):S67-SS116.

16. Errors in This Case
In the present case, appropriate prescription practices were not followed
First error was prescribing both long-acting morphine and oxycodone in a patient with asthma, who lacked support systems or stable housing
May have been more appropriate to start with a single short-acting agent

17. Errors in This Case (2)
Second error was decision to switch patient to methadone, even though he admitted to selling opioids and purchasing diazepam and methadone
Hospitalist likely should have tried to manage patient's pain with short-acting oxycodone (given adverse effects of methadone)

18. The evidence is also limited that screening will reduce abuse
Screening for Abuse
Limited evidence for reliability and accuracy of available screening instruments
The evidence is also limited that screening will reduce abuse
Prescription drug monitoring programs (large databases that collect prescription data) may help reduce risks in opioid prescribing
Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–Guidance. Pain Physician. 2012;15(3 suppl):S67-SS116.

19. Screening for Abuse (2)
Good evidence that prescription drug monitoring programs provide data on patterns of prescription drug usage, which may lead to earlier recognition of abuse
Fair evidence that prescription drug monitoring programs may reduce prescription drug abuse or doctor shopping
However, only limited evidence that prescription drug monitoring programs reduce emergency room visits, drug overdoses, or deaths
Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–Guidance. Pain Physician. 2012;15(3 suppl):S67-SS116.

20. Adherence Monitoring
Urine drug testing, as part of compliance monitoring, is crucial in managing opioid therapy
While patients may balk at this testing, urine drug screening should be used as an exercise to strengthen the patient–physician relationship
Urine drug testing may identify patients who are noncompliant and may decrease prescription drug abuse or illicit drug use
Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–Guidance. Pain Physician. 2012;15(3 suppl):S67-SS116.

21. Pain Contracts
Providers may choose to engage patients in formal treatment agreement (i.e., pain contract)
Informed consent essential
Consequences of violating contract should be clear

22. Risk Stratification
Stratification of risk for patients initiated or maintained on chronic opioid therapy is crucial to prevent misuse and abuse
Can be classified into low, medium, and high risk
Patients with concurrent substance abuse and high risk for abusing prescription opiates fall under the category of high risk
High-risk patients need more monitoring and repeat assessments
High-risk patients should be on low-dose opioids (not combination therapy) and weaned off if they have aberrant behaviors

23. This Case
This patient had significant abuse patterns and should have been considered high risk
He likely never should have been initiated on high-dose opioid therapy
He should have been appropriately monitored and potentially weaned off his opiates, or referred to addiction management

24. Take-Home Points
The initial assessment in managing patients with chronic non-cancer pain should involve establishing the diagnosis, medical necessity, and treatment goals
The most common errors associated with opioid prescribing for non-cancer pain include: inadequate screening for safe and effective opioid use, inability to monitor adherence, improper selection of opioids, and insufficient consideration of comorbid conditions

25. Take-Home Points (2)
Providers should obtain full informed consent before prescribing opioids and determine methods to monitor adherence
Patients who are prescribed opioids should be monitored continuously for adherence and adverse effects as well as screened for abuse; urine drug testing may be effective
Stratifying patients into low, medium, and high risk is essential prior to embarking on initial treatment