While important for pain relief, opioids are the class of medications most frequently reported in adverse drug events resulting in harm. A comprehensive approach may help manage risk, and generally includes careful patient evaluation, a clear treatment plan, informed consent, periodic review (monitoring of efficacy and side effects), consultation with other physicians or providers when necessary, careful documentation, and compliance with applicable laws and regulations. 1
Physicians can consult clinical practice guidelines, such as the Guideline for opioid therapy and chronic non-cancer pain, which supports appropriate prescribing. Physicians should also familiarize themselves with practice guidelines, standards of practice, and any other resources offered by their College in relation to the use of opioids for the management of non-cancer pain.
Talking to patients about pain medication
When starting opioids, or restarting a prescription after a long absence, you should talk to patients about issues such as: the reason for the medication; the drug’s benefits and risk of harm; drug interactions; symptoms and signs that might indicate an adverse reaction; and any ongoing monitoring that may be required. You may also consider whether creating an opioid medication treatment contract would be appropriate.
It is important to assess the underlying motivation of a patient who is seeking pain medication and ensure their understanding of the treatment of chronic pain. The actual discussion with the patient regarding opioid misuse can be difficult, especially with patients who have been prescribed long-term opioids by another healthcare provider.
The following strategies may be helpful in managing expectations and discussing medication use — including opioids — with a patient:
- Be empathetic and acknowledge the patient’s suffering.
- Maintain a respectful, supportive relationship with the patient.
- Be firm and confident in the presentation of information, explain your approach to using opioid medication for chronic pain, and encourage honest responses by using simple, open-ended questions.
- Clearly communicate any opioid prescription and refill policies.
- Discuss your intentions to contact the patient’s other healthcare providers to advance the patient’s care, and obtain the patient’s permission to do so.
- Maintain privacy and strict confidentiality to make patients comfortable and open to sharing their concerns.
- Document all discussion and treatment decisions, and verify that the patient understands and accepts any agreement letters or contracts.
Identifying drug-seeking behaviour
All physicians, and pain management specialists in particular, may face significant challenges when assessing patients experiencing pain and determining if they legitimately require opioid medication to help treat their condition.
Physicians should be particularly vigilant when patients say they have lost their prescription or medication, or when they request specific opioid medications or precise dosages.
When examining patients who are seeking opioid medications, physicians should consider the extent to which a patient’s pattern of pain and overall clinical condition has changed with treatment. It is important to have a thorough understanding of the patient’s past and present condition, and to look for consistency in the results of physical or psychological assessments (pain, function). Appropriate tests, possibly including a risk assessment for substance abuse, may also be warranted.
A patient who repeatedly returns with unresolved complaints, or with symptoms that worsen or are not responding to treatment, may signal an unsuspected serious medical condition. Physicians should keep an open mind and reflect on any diagnosis, being careful to consider other possibilities, including those that may be life-threatening.
Physicians should also be mindful of their own emotional responses and biases, as well as those of other team members, which may interfere with the objective assessment of a particular patient.
Preventing drug diversion
“Drug diversion” refers to the use of prescription medication for unauthorized purposes, or the transfer of medication from lawful to unlawful distribution or use. Patients may divert both opioids and non-opioid medications for their own use, or to give or sell to others. Patients may “doctor-shop,” “double-doctor,” or engage in prescription fraud. For more information on responding to these sorts of behaviours, see Suspect unlawful activity with prescriptions or medications?
Since opioid abuse may involve family members or roommates illegally accessing or selling the patient’s opioids, it may be appropriate to discuss the importance of secure medication storage and the risk of drug diversion in the patient’s home.
Patients who abuse opioids or divert drugs may visit clinics specifically to try to obtain opioids. They may indicate they are on long-term opioid therapy and have run out of their medication or are unable to access their usual health care provider, and ask for a temporary prescription. Physicians should remember they retain the professional responsibility for every prescription they write. Physicians working in clinics and facilities should familiarize themselves with any organizational policies concerning opioid prescribing, as this may enable a consistent response from all physicians at the facility.
A patient’s repeated misuse of opioids can create tension in the physician-patient relationship. Depending on the circumstances, a physician may wish to end the relationship. Ending the relationship may also be appropriate if a patient is persistently uncooperative and where there is a breakdown in trust. Physicians should be familiar with any policies or guidelines from their College on steps to take in ending the doctor-patient relationship.
Toombs, James D., “Commonsense opioid risk management in chronic non-cancer pain,” Practical Pain Management (2012) Vol.8, No.3.