Education a Cornerstone of Effective Opioid Management

LAS VEGAS – Even the most careful clinical pain management cannot eliminate the risk of opioid misuse in patients with a history of addiction, but good communication can help reduce the risk significantly, Dr. Sean Mackey said during a psychopharmacology conference sponsored by the Nevada Psychiatric Association.

"Some of the basic tenets of managing patients with chronic opioids are education, education, and education," said Dr. Mackey, chief of the pain management division at Stanford (Calif.) University. "It’s important to set expectations for people with chronic pain. The cure is not the goal; we’re there to help improve quality of life and get people back in control of their lives, better manage pain, and improve physical functioning."

According to best estimates from existing medical literature, the prevalence of comorbid chronic pain and opioid addiction in the United States ranges between 0.6-1.2 million people, mainly affecting young adults and the elderly. But that estimate might be conservative. A June 2011 report from the Institute of Medicine noted that chronic pain affects 116 million Americans – more than the total affected by heart disease, cancer and diabetes combined – at a cost of $560-$630 billion per year. Chronic pain "is the No. 1 reason people are out of work, hitting people often at their most productive ages, and also hitting people more and more as we advance in years," Dr. Mackey said.

In his opinion, optimal management of patients with chronic pain consists of a multidisciplinary approach "in which we bring together specialists who take care of pharmacologic aspects to pain management, physical and occupational therapy approaches, psychological/behavioral approaches, and complementary and alternative medicine approaches. It’s a team-based approach. A lot of this is dealing with body education: helping people understand what is safe for them to do and what is not safe for them to do, alleviating their fears about their body.

"We do procedural approaches as well, everything from simple trigger-point injections to spinal cord stimulation – all in the context of a functional rehabilitation approach."

Psychological approaches include giving patients time-contingent dosing of medications, "on-the-clock rather than when they are experiencing pain," said Dr. Mackey, who also directs the Stanford Systems Neuroscience and Pain Lab. "We also give positive reinforcement for healthy behaviors, negative reinforcement for unhealthy behaviors, and we get their spouse involved, because their involvement is crucial to success."

To responsibly prescribe opioids, Dr. Mackey recommends that physicians become familiar with the Federation of State Medical Boards’ Model Policy for the Treatment of Pain. He also recommends the book "Responsible Opioid Prescribing: A Physician’s Guide," by pain expert Dr. Scott M. Fishman (Waterford, Mich.: Waterford Life Sciences, 2007). This book incorporates the tenets set out in the FSMB’s model policy. "The basic tenet of this model is that pain management is a moral imperative; we should all be aware of the problems of pain management and the use of opioids may be necessary for our patients in pain," Dr. Mackey said.

The model also emphasizes that the use of opioids other than for a legitimate medical purpose "does pose a problem, that we have a responsibility to minimize the abuse and diversion with risk mitigation, [and] that physicians may deviate from recommended treatment when they have good cause. That means we’re not trying to box people in to rigid policies."

His recommended strategy for prescribing opioids in patients with a history of substance abuse starts with a careful assessment and formation of an appropriate differential diagnosis and a psychological assessment, including risk of addictive disorders. Next, have patients sign an informed consent for opioid treatment. "Our consent form has changed somewhat," Dr. Mackey said. "I’m giving patients more information about the potential for organ toxicity and the endocrine abnormalities that can occur as a consequence of opioid use, such as depression of sex hormones."

This is followed by asking patients to sign an opioid treatment agreement that informs them about your standard opioid prescribing policy, such as stating that medication will be refilled during regular office hours, Mondays through Fridays, that lost narcotic medication cannot be replaced, and that stolen narcotic medication may be replaced provided they obtain a police report and are seen in the office.

Dr. Mackey then begins patients on an appropriate trial of opioid therapy with or without adjunctive medications.

"I use the word ‘trial’ because people often think this is meant to be a long-term use of these medications when we try to make it clear right up front that use is for the short term," he explained. "I then assess and reassess their level of pain and function."

He also recommends that clinicians follow the "four As" for ongoing monitoring of pain treatment outcomes, a system developed by Steven D. Passik, Ph.D. These are analgesia (pain relief), activities of daily living (psychosocial functioning), adverse events (side effects), and aberrant drug taking (addiction-related outcomes).

"If you focus on those four As and document them, you can usually stay out of trouble when prescribing these medications," Dr. Mackey said. "Document everything in the medical record, because 95% of the problems that doctors run into with their state medical board have to do with failure to appropriately document."

Other efforts to mitigate risk include using predictive tools, urine drug testing when appropriate, and using your state’s prescription monitoring program. "Use family and friends and others to gather information to make sure that the patient is using the medication appropriately," he advised.

Potential signs of abuse and diversion include patients "who show up at the end of office hours and arrive without an appointment, or who often arrive right when your staff is trying to leave for the day," Dr. Mackey said. "They’re typically reluctant to have a thorough physical exam and don’t give you past medical records, they don’t follow up with appointments, and they have very unusual stories."

Dr. Mackey disclosed that he has received research funding from the National Institutes of Health, the Dodie and John Rosekrans Pain Research Endowment, and the Redlich Pain Research Endowment.

LAS VEGAS – Even the most careful clinical pain management cannot eliminate the risk of opioid misuse in patients with a history of addiction, but good communication can help reduce the risk significantly, Dr. Sean Mackey said during a psychopharmacology conference sponsored by the Nevada Psychiatric Association.

"Some of the basic tenets of managing patients with chronic opioids are education, education, and education," said Dr. Mackey, chief of the pain management division at Stanford (Calif.) University. "It’s important to set expectations for people with chronic pain. The cure is not the goal; we’re there to help improve quality of life and get people back in control of their lives, better manage pain, and improve physical functioning."

According to best estimates from existing medical literature, the prevalence of comorbid chronic pain and opioid addiction in the United States ranges between 0.6-1.2 million people, mainly affecting young adults and the elderly. But that estimate might be conservative. A June 2011 report from the Institute of Medicine noted that chronic pain affects 116 million Americans – more than the total affected by heart disease, cancer and diabetes combined – at a cost of $560-$630 billion per year. Chronic pain "is the No. 1 reason people are out of work, hitting people often at their most productive ages, and also hitting people more and more as we advance in years," Dr. Mackey said.

In his opinion, optimal management of patients with chronic pain consists of a multidisciplinary approach "in which we bring together specialists who take care of pharmacologic aspects to pain management, physical and occupational therapy approaches, psychological/behavioral approaches, and complementary and alternative medicine approaches. It’s a team-based approach. A lot of this is dealing with body education: helping people understand what is safe for them to do and what is not safe for them to do, alleviating their fears about their body.

"We do procedural approaches as well, everything from simple trigger-point injections to spinal cord stimulation – all in the context of a functional rehabilitation approach."

Psychological approaches include giving patients time-contingent dosing of medications, "on-the-clock rather than when they are experiencing pain," said Dr. Mackey, who also directs the Stanford Systems Neuroscience and Pain Lab. "We also give positive reinforcement for healthy behaviors, negative reinforcement for unhealthy behaviors, and we get their spouse involved, because their involvement is crucial to success."

To responsibly prescribe opioids, Dr. Mackey recommends that physicians become familiar with the Federation of State Medical Boards’ Model Policy for the Treatment of Pain. He also recommends the book "Responsible Opioid Prescribing: A Physician’s Guide," by pain expert Dr. Scott M. Fishman (Waterford, Mich.: Waterford Life Sciences, 2007). This book incorporates the tenets set out in the FSMB’s model policy. "The basic tenet of this model is that pain management is a moral imperative; we should all be aware of the problems of pain management and the use of opioids may be necessary for our patients in pain," Dr. Mackey said.

The model also emphasizes that the use of opioids other than for a legitimate medical purpose "does pose a problem, that we have a responsibility to minimize the abuse and diversion with risk mitigation, [and] that physicians may deviate from recommended treatment when they have good cause. That means we’re not trying to box people in to rigid policies."

His recommended strategy for prescribing opioids in patients with a history of substance abuse starts with a careful assessment and formation of an appropriate differential diagnosis and a psychological assessment, including risk of addictive disorders. Next, have patients sign an informed consent for opioid treatment. "Our consent form has changed somewhat," Dr. Mackey said. "I’m giving patients more information about the potential for organ toxicity and the endocrine abnormalities that can occur as a consequence of opioid use, such as depression of sex hormones."

This is followed by asking patients to sign an opioid treatment agreement that informs them about your standard opioid prescribing policy, such as stating that medication will be refilled during regular office hours, Mondays through Fridays, that lost narcotic medication cannot be replaced, and that stolen narcotic medication may be replaced provided they obtain a police report and are seen in the office.

Dr. Mackey then begins patients on an appropriate trial of opioid therapy with or without adjunctive medications.

"I use the word ‘trial’ because people often think this is meant to be a long-term use of these medications when we try to make it clear right up front that use is for the short term," he explained. "I then assess and reassess their level of pain and function."

He also recommends that clinicians follow the "four As" for ongoing monitoring of pain treatment outcomes, a system developed by Steven D. Passik, Ph.D. These are analgesia (pain relief), activities of daily living (psychosocial functioning), adverse events (side effects), and aberrant drug taking (addiction-related outcomes).

"If you focus on those four As and document them, you can usually stay out of trouble when prescribing these medications," Dr. Mackey said. "Document everything in the medical record, because 95% of the problems that doctors run into with their state medical board have to do with failure to appropriately document."

Other efforts to mitigate risk include using predictive tools, urine drug testing when appropriate, and using your state’s prescription monitoring program. "Use family and friends and others to gather information to make sure that the patient is using the medication appropriately," he advised.

Potential signs of abuse and diversion include patients "who show up at the end of office hours and arrive without an appointment, or who often arrive right when your staff is trying to leave for the day," Dr. Mackey said. "They’re typically reluctant to have a thorough physical exam and don’t give you past medical records, they don’t follow up with appointments, and they have very unusual stories."

Dr. Mackey disclosed that he has received research funding from the National Institutes of Health, the Dodie and John Rosekrans Pain Research Endowment, and the Redlich Pain Research Endowment.

LAS VEGAS – Even the most careful clinical pain management cannot eliminate the risk of opioid misuse in patients with a history of addiction, but good communication can help reduce the risk significantly, Dr. Sean Mackey said during a psychopharmacology conference sponsored by the Nevada Psychiatric Association.

"Some of the basic tenets of managing patients with chronic opioids are education, education, and education," said Dr. Mackey, chief of the pain management division at Stanford (Calif.) University. "It’s important to set expectations for people with chronic pain. The cure is not the goal; we’re there to help improve quality of life and get people back in control of their lives, better manage pain, and improve physical functioning."

According to best estimates from existing medical literature, the prevalence of comorbid chronic pain and opioid addiction in the United States ranges between 0.6-1.2 million people, mainly affecting young adults and the elderly. But that estimate might be conservative. A June 2011 report from the Institute of Medicine noted that chronic pain affects 116 million Americans – more than the total affected by heart disease, cancer and diabetes combined – at a cost of $560-$630 billion per year. Chronic pain "is the No. 1 reason people are out of work, hitting people often at their most productive ages, and also hitting people more and more as we advance in years," Dr. Mackey said.

In his opinion, optimal management of patients with chronic pain consists of a multidisciplinary approach "in which we bring together specialists who take care of pharmacologic aspects to pain management, physical and occupational therapy approaches, psychological/behavioral approaches, and complementary and alternative medicine approaches. It’s a team-based approach. A lot of this is dealing with body education: helping people understand what is safe for them to do and what is not safe for them to do, alleviating their fears about their body.

"We do procedural approaches as well, everything from simple trigger-point injections to spinal cord stimulation – all in the context of a functional rehabilitation approach."

Psychological approaches include giving patients time-contingent dosing of medications, "on-the-clock rather than when they are experiencing pain," said Dr. Mackey, who also directs the Stanford Systems Neuroscience and Pain Lab. "We also give positive reinforcement for healthy behaviors, negative reinforcement for unhealthy behaviors, and we get their spouse involved, because their involvement is crucial to success."

To responsibly prescribe opioids, Dr. Mackey recommends that physicians become familiar with the Federation of State Medical Boards’ Model Policy for the Treatment of Pain. He also recommends the book "Responsible Opioid Prescribing: A Physician’s Guide," by pain expert Dr. Scott M. Fishman (Waterford, Mich.: Waterford Life Sciences, 2007). This book incorporates the tenets set out in the FSMB’s model policy. "The basic tenet of this model is that pain management is a moral imperative; we should all be aware of the problems of pain management and the use of opioids may be necessary for our patients in pain," Dr. Mackey said.

The model also emphasizes that the use of opioids other than for a legitimate medical purpose "does pose a problem, that we have a responsibility to minimize the abuse and diversion with risk mitigation, [and] that physicians may deviate from recommended treatment when they have good cause. That means we’re not trying to box people in to rigid policies."

His recommended strategy for prescribing opioids in patients with a history of substance abuse starts with a careful assessment and formation of an appropriate differential diagnosis and a psychological assessment, including risk of addictive disorders. Next, have patients sign an informed consent for opioid treatment. "Our consent form has changed somewhat," Dr. Mackey said. "I’m giving patients more information about the potential for organ toxicity and the endocrine abnormalities that can occur as a consequence of opioid use, such as depression of sex hormones."

This is followed by asking patients to sign an opioid treatment agreement that informs them about your standard opioid prescribing policy, such as stating that medication will be refilled during regular office hours, Mondays through Fridays, that lost narcotic medication cannot be replaced, and that stolen narcotic medication may be replaced provided they obtain a police report and are seen in the office.

Dr. Mackey then begins patients on an appropriate trial of opioid therapy with or without adjunctive medications.

"I use the word ‘trial’ because people often think this is meant to be a long-term use of these medications when we try to make it clear right up front that use is for the short term," he explained. "I then assess and reassess their level of pain and function."

He also recommends that clinicians follow the "four As" for ongoing monitoring of pain treatment outcomes, a system developed by Steven D. Passik, Ph.D. These are analgesia (pain relief), activities of daily living (psychosocial functioning), adverse events (side effects), and aberrant drug taking (addiction-related outcomes).

"If you focus on those four As and document them, you can usually stay out of trouble when prescribing these medications," Dr. Mackey said. "Document everything in the medical record, because 95% of the problems that doctors run into with their state medical board have to do with failure to appropriately document."

Other efforts to mitigate risk include using predictive tools, urine drug testing when appropriate, and using your state’s prescription monitoring program. "Use family and friends and others to gather information to make sure that the patient is using the medication appropriately," he advised.

Potential signs of abuse and diversion include patients "who show up at the end of office hours and arrive without an appointment, or who often arrive right when your staff is trying to leave for the day," Dr. Mackey said. "They’re typically reluctant to have a thorough physical exam and don’t give you past medical records, they don’t follow up with appointments, and they have very unusual stories."

Dr. Mackey disclosed that he has received research funding from the National Institutes of Health, the Dodie and John Rosekrans Pain Research Endowment, and the Redlich Pain Research Endowment.