How to Institute Guardrails when Prescribing Opiates for Non-Cancer Pain

Prescribing opiates for non-cancer pain is an evolving field for clinicians. What was appropriate 5 years ago would be considered poor practice today, making it critical for practitioners to stay current in their knowledge. We started using opiates for chronic pain without malignancy about 20 years ago. Before then, patients were forced to live with whatever pain remained after all non-opioid treatments were exhausted. For some individuals, their pain left them disabled and homebound. A percentage of these patients would experience a better quality of life with opiates and clinicians were pressured to prescribe them.

How to Institute Guardrails when Prescribing Opiates for Non-Cancer PainUntil recently, there was very little research available to help determine opiate dosages and risks. As far as we knew, there was no known ceiling on dosing, which led to a decade of excessive doses and overdose deaths. Unfortunately, this also created a population of patients who relied on long term opiates. Studies on these drugs indicate that they may change the central nervous system in a way that makes future abstinence impossible. This is the reason that methadone maintenance is offered as a treatment for opioid addiction.

What have we learned over this painful decade that now defines a standard of care? Guidelines have emerged recently and are still evolving. As a member of a State Medical Board, I can attest that we must evaluate how clinicians are following guidelines to ensure that they “first, do no harm.” Any clinician who manages patients with chronic pain should have the following guardrails in place:

  1. Prior to initially prescribing opiates for chronic pain, patients must be well informed about risks, a Care Plan must be produced, and a treatment agreement should be signed.
  2. Random urine drug screens must be ordered and any detected problems must be addressed.
  3. Every effort must be made to keep the dosing as low as possible. Doses above 40 MEQ (morphine equivalent doses) are currently rated as moderate risk and above 90 MEQ is high risk.
  4. Clinicians must monitor for addiction and have exit plans in place for patients in which dependence emerges.
  5. Monitor functional improvement and/or decline as indicators for dosing.

We now know that opiates do in fact have a ceiling of effectiveness. At their best, they may only control about 30% of total pain. We can reduce pain but cannot eliminate it entirely. Chasing total control with these medications is dangerous and ineffective. I’d encourage medical professionals to review U.S. Surgeon General Vivek Murthy’s Turn the Tide website and download the Pocket Guide for Prescribing Opioids for Chronic Pain >>

If you’d like help standardizing opioid prescribing practices within your organization, please complete the contact form on the sidebar or call 925-265-4113, ext. 5.

Claire Trescott, M.D.

Claire Trescott, M.D.
Practicing Physician & Former Primary Care Medical Director
HCIM Senior Executive Adviser

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