The safe and appropriate treatment of pain is a priority in Ohio. The Governor’s Cabinet Opiate Action Team (GCOAT), and a group of professional health care provider licensing boards, associations, individual providers and other key stakeholders have focused their most recent supportive efforts on the further education of health care professionals and patients. Our goal is to help reduce and eliminate the misuse and abuse of opioid drugs in Ohio. Our message is the same for other controlled substances and the prescription drug tramadol that have similar misuse and abuse potential. We would like you to read and embrace the following “guidelines for Prescribing Opioids for the Treatment of Chronic, Non-terminal Pain” in your practice.
Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-Terminal Pain
80 mg of a Morphine Equivalent Daily Dose (MED) “Trigger Point”
These guidelines address the use of opioids for the treatment of chronic, non-terminal pain. "Chronic pain" means pain that has persisted after reasonable medical efforts have been made to relieve the pain or cure its cause and that has continued, either continuously or episodically, for longer than three continuous months. The guidelines are intended to help health care providers review and assess their approach in the prescribing of opioids. The guidelines are points of reference intended to supplement and not replace the individual prescriber’s clinical judgment. The 80 mg MED is the maximum daily dose at which point the prescriber’s actions are triggered; however, this 80 mg MED trigger point is not an endorsement by any regulatory body or medical professional to utilize that dose or greater.
Recent analysis by the Centers for Disease Control and Prevention (CDC) shows that “patients with mental health and substance use disorders are at increased risk for nonmedical use and overdose from prescription painkillers as well as being prescribed high doses of these drugs.” Drug overdose deaths increased for the 11th consecutive year in 2010. Nearly 60% of the deaths involved pharmaceuticals, and opioids were involved in nearly 75%. Researchers also found that drugs prescribed for mental health conditions were involved in over half. These findings appear consistent with research previously published in the Annals of Internal Medicine that concluded that “patients receiving higher doses of prescribed opioids are at an increased risk for overdose, which underscores the need for close supervision of these patients” (Dunn, et al., 2010).
Health care providers are not obligated to use opioids when a favorable risk-benefit balance cannot be documented. Providers should first consider non-pharmacologic and non-opioid therapies. Providers should exercise the same caution with tramadol as with opioids and must take into account the medication’s potential for abuse, the possibility the patient will obtain the medication for a nontherapeutic use or distribute it to other persons, and the potential existence of an illicit market for the medication.
Providers must be vigilant to the wide range of potential adverse effects associated with long-term opioid therapy and misuse of extended-release formulations. That vigilance and detailed attention has to be present from the outset of prescribing and continue for the duration of treatment. Providers should avoid starting a patient on long-term opioid therapy when treating chronic pain. Providers should also avoid prescribing benzodiazepines with opioids as it may increase opioid toxicity, add to sleep apnea risk, and increase risk of overdose deaths and other potential adverse effects.
Providers can further minimize the potential for prescription drug abuse/misuse and help reduce the number of unintentional overdose deaths associated with pain medications by recognizing times to “press pause” in response to certain “trigger points.” This pause allows providers to reassess their compliance with accepted and prevailing standards of care. The 80 mg Morphine Equivalent Daily Dose (MED) “trigger point” is one such time.
Providers treating chronic, non-terminal pain patients who have received opioids equal to or greater than 80 mg MED for longer than three continuous months should strongly consider doing the following to optimize therapy and help ensure patient safety:
The 80 MED “trigger point” is an opportunity to review the plan of treatment, the patient's response to treatment, and any modification to the plan of treatment that is necessary to achieve a favorable risk-benefit balance for the patient’s care. If opioid therapy is continued, further reassessment will be guided by clinical judgment and decision-making consistent with accepted and prevailing standards of care. The “trigger point” also provides an opportunity to further assess addiction risk or mental health concerns, possibly using Screening, Brief Intervention, and Referral to Treatment (SBIRT) tools, including referral to an addiction medicine specialist when appropriate.
For providers treating acute exacerbation of chronic, non-terminal pain, clinical judgment may not trigger the need for using the full array of reassessment tools.
Providers treating patients with acute care conditions in the emergency department or urgent care center should refer to the Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances Prescribing Guidelines.