Appropriate prescribing critical to manage pain drugs

August 1, 2010

Stronger opioids such as morphine, hydromorphone, oxymorphone, methadone, levorphanol, fentanyl and oxycodone are generally used for treatment of moderate to severe pain.

The opioid family of medications is used for its effective pain-relieving properties. Stronger opioids such as morphine, hydromorphone, oxymorphone, methadone, levorphanol, fentanyl and oxycodone are generally used for treatment of moderate to severe pain. Weaker opioids, such as codeine, are often combined with nonopioid pain relievers and prescribed for mild pain.

"Opioid dose requirements vary widely from one patient to another, but 10 milligrams of morphine per 70 kilograms of body weight or its equivalent is a reasonable starting dose," says Mark Abramowicz, MD, editor-in-chief of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs. "There is generally no maximum dose except when limited by the dose of aspirin, acetaminophen or ibuprofen in fixed-dose combination preparations."

Morphine is the standard of comparison, but patients who do not respond to one opioid may respond to another. The dose required to maintain optimum pain relief with tolerable side effects should be used, he says.

Dizziness, nausea, vomiting and sleepiness are among the most common adverse side effects of opioids. The most serious potential side effect is respiratory depression.

"Tolerance to most of the adverse effects of opioids, including respiratory and central nervous system depression, develops at least as rapidly as tolerance to the analgesic effect. Tolerance can, therefore, usually be surmounted and adequate analgesia restored by increasing the dose," says Dr. Abramowicz. "When frequent dosing becomes impractical, long-acting opioids may be helpful."

STOPPING PAIN IN ITS TRACKS

CareOregon, a health plan serving 120,000 low income members in 17 Oregon counties, has been working on the issue of appropriate prescribing for opioid medications over the past decade.

"This is an important long-term issue for us," says David Labby, MD, medical director. "People who are in chronic pain often end up not being able to work, so our membership tends to be over-represented in terms of chronic pain."

In 2003, CareOregon published a handbook for physicians on the use of opioids in the treatment of chronic pain.

"We included information on an appropriate evaluation, possible approaches to take, and how to use various medications," Dr. Labby says. "I went around to our clinical partners and gave multiple talks on how to approach prescribing for chronic pain."

CareOregon considers patient self-management to be an essential aspect of dealing with chronic pain.

In the past several years, the plan provided funding to clinics to set up chronic-pain classes, and they were effective, he says.

Additionally, CareOregon and its major primary care partners developed an opioid task force to agree on the basic elements of a clinical chronic pain program.

"In the past, if one clinic was fairly liberal with medications while another was fairly tight, people would tend to gravitate to the [liberal] clinic," says Dr. Labby. "You need to have all providers on the same page. We worked to create standards of care for chronic pain patients which are now used in our largest network clinics."

Many of the clinics do risk screenings, so a patient who is at risk for addiction is identified early in the process. All patients receive random urine drug tests to check for possible overuse or underuse of prescribed medications.

A key element to the standardized approach is to set up a clinic opioid oversight committee so any provider can internally refer a specific patient's case for review by clinical peers. An opioid oversight committee can establish a peak opioid dosage and require any case over that dosage to be referred, can deal with difficult cases where the use or escalation of opioids is in question, and can deal with problematic clinician-patient relationships.