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Chronic Opioid Rules
Randall Lee Oliver, MD; April Taylor, RN
Posted: April 2005  
Practical Pain Management; Mar/Apr 2003

Opioids are potentially dangerous medications that can lead to accidental overdose, death, or impairment around machinery, or while driving an automobile. Therefore -- even for the chronic pain patients who generally need opioids to improve functionality -- they should be used judiciously and wisely.

Rule No. 1:  There should be a single prescribing physician using a multidisciplinary approach to pain management. Dosages must be monitored and re-evaluated with monthly visits and, because there is only one managing physician, the risk of overdose and withdrawal is eliminated.

Rule No. 2:  Complete a thorough history and physical. Releases should be signed for any previous providers regarding previous treating doctors and/or substance treatment and/or psychological evaluations. Before a physician prescribes a chronic opioid, the patient must have failed first line treatments. Chronic opioid use is not appropriate until non-opioid options have been tried and found inadequate. These include NSAIDs, Ultram, trigger-point injections, physical therapy, and chiropractic care. Documentation of this failure must be shown.

Rule # 3:  Perform urine drug screens on suspected abusers.

Rule # 4:  Make appropriate consults; share the responsibility of treatment of the chronic pain syndrome. Since most chronic pain patients will eventually develop severe depression and/or anxiety as part of the syndrome, psychological care must be addressed as part of the overall treatment of chronic pain.

Rule # 5:  Co-morbid conditions must be identified and treated. Pain cannot be controlled unless the co-morbid conditions of fatigue, insomnia, sexual dysfunction, anxiety and depression are also controlled.

Rule # 6:  Monthly visits with accompanying documentation of symptoms and improvement of function is necessary to show continued need for the opioids. Constant re-evaluation for success and monitoring for warning signs of addiction or abuse is an ongoing process.

Rule # 7:  A signed contract or opioid agreement should be on file. The contract must easily and completely describe the risks and benefits of opioid use. Consequences for non-compliance is key. Only give opioids to patients who follow the plan.

Rule # 8:  Use long-acting opioids for chronic pain and avoid the short-acting opioids -- except for breakthrough pain. Avoid mixing long-acting opioids with other long-acting opioids and, likewise, short-acting opioids with other short- acting opioids.

Rule # 9:  When prescribing long-acting opioids, the dose should be determined by the maximum effective dose, not the maximum tolerated dose. Maximum tolerated dose would be infinite because you can gradually work up to any dose. Maximum effective dose is the dose that gives the maximum functionality while recognizing that relief in a chronic pain patient is not a totally pain-free state.

Rule # 10:  Do not prescribe opioids to drug abusers. A drug addict has no ability to control himself when narcotics are present.

Summary:  Each patient needs to be monitored closely for risks and benefits and reevaluated at every visit for the continued need of opioid therapy.