Key Point
The risk of overdose begins to increase at doses equivalent to morphine, 50 to 100 mg/day, and continues to rise in a dose-dependent fashion.
Studies are not yet available to show whether patients who do not respond at morphine-equivalent doses <50 to 100 mg/day will respond at higher doses. Anecdotally, however, many patients who do not respond at lower doses also do not appear to respond at higher doses of the same opioid, or respond minimally. Therefore, prescribe opioids at doses equivalent to morphine >100 mg/day only for patients with clearly demonstrated improvement in pain and function whom you can adequately monitor.
Include these in the treatment plan
As part of the treatment plan, be sure to define measurable, achievable functional goals for all patients to help assess benefits from opioids. For example, walking the dog for 20 minutes 5 times a week is a feasible and measurable functional goal for a 60-year-old patient, whereas a goal to “feel 25 years old again” is not.
Key Point
Define measurable, achievable functional goals to help assess benefits from opioids.
Always have an “exit strategy” when starting opioids, with a clear understanding of circumstances that will lead to opioid discontinuation (such as inability to take opioids as prescribed, noncompliance with other recommended interventions or follow-up, or illicit drug use) as well as a plan on how to taper opioids, including resources for managing withdrawal. Outline this opioid management plan in writing, including reasons for discontinuation, making the treatment parameters clear to the patient and other health care providers from the onset.
CASE
Mr. S has no personal or family history of substance abuse, no history of depression or other psychological disorders, and no serious comorbid conditions that are contraindications to opioid therapy. He scores 0 points on the Opioid Risk Tool, and a urine drug screen is negative. You initiate low-dose opioid therapy (oxycodone 5 mg 3 times daily as needed). You set a goal that Mr. S walk 30 minutes 4 times a week, with a longer-term goal of walking 9 holes of golf.
Continually reassess
Consider the period after you initiate opioids as a treatment trial, and constantly reexamine the decision to continue opioids.25 In follow-up, carefully assess for pain and functional status as well as signs of aberrant drug-related behaviors or other adverse effects.
When a patient is not benefiting from opioids in terms of reduced pain and improved function or is experiencing adverse effects, consider whether to discontinue or restructure opioid therapy. You might try a lower dose, intensify monitoring, consider a specialty consultation, or take other measures. Importantly, patients who are discontinued from opioids still need help to manage their pain, as well as withdrawal symptoms and addiction (when present). They frequently benefit from interventions designed to improve function and address psychological comorbidities and maladaptive coping strategies. Options include psychologically informed physical therapy, interdisciplinary rehabilitation, and cognitive behavioral therapy.
Key Point
Patients who are discontinued from opioids still need help to manage their pain.
CASE
At follow-up in 4 weeks, Mr. S reports his pain level has gone down from an average of 7 out of 10 to 4 out of 10, and he has been able to walk 20 to 30 minutes 4 times a week. He has no signs of aberrant behaviors. You decide to continue opioid therapy at the same low dose and reiterate the importance of reaching and maintaining functional goals. At this point, you plan to continue the opioid medication as long as he shows continued improvement in functionality and has no signs of aberrant behaviors. You schedule the next follow-up visit in 8 weeks.