Finding Pain Management Doctors That Prescribe Narcotics: Understanding Your Options and Risks

Navigating chronic pain can be a challenging journey, and for many individuals, the question of pain management doctors who prescribe narcotics becomes a central point of their search for relief. It’s essential to understand the complexities surrounding this topic, from when opioid therapy might be considered to the critical importance of responsible prescribing and risk management. This guide, based on established recommendations for chronic pain management, aims to provide a comprehensive overview for those seeking information about pain management and narcotic prescriptions.

When to Consider Opioid Therapy for Chronic Pain

1. Prioritizing Non-Pharmacological and Non-Opioid Treatments:

The cornerstone of effective chronic pain management begins with non-pharmacological and non-opioid pharmacologic therapies. These approaches are preferred as initial treatments due to their effectiveness and lower risk profiles compared to opioids. Pain management doctors will often recommend a combination of these therapies before even considering narcotics.

Non-pharmacological options encompass a wide range of treatments, including:

• Physical Therapy: Exercise therapy, a key component of physical therapy, has demonstrated significant benefits in reducing pain and improving function for conditions like hip and knee osteoarthritis. Improvements can be sustained for several months. Exercise can also be beneficial for low back pain and fibromyalgia.
• Psychological Therapies: Cognitive Behavioral Therapy (CBT) and other psychological approaches can play a crucial role in managing chronic pain by addressing the emotional and psychological aspects of pain, improving coping mechanisms, and enhancing function.
• Interventional Procedures: Injections like arthrocentesis and intra-articular glucocorticoid injections for arthritis, or corticosteroid injections for rotator cuff issues, can provide short-term pain relief and improved function.
• Multimodal and Multidisciplinary Rehabilitation: Combining psychological therapies with exercise and other approaches can offer more effective long-term pain and disability reduction compared to single treatments.

Non-opioid pharmacologic therapies also provide effective alternatives for chronic pain management. These include:

• Acetaminophen and NSAIDs: These are commonly used for arthritis and low back pain. However, it’s important to be aware of potential risks, especially with long-term NSAID use, particularly for older adults and those with cardiovascular, renal, gastrointestinal, or liver conditions.
• Antidepressants and Anticonvulsants: Certain antidepressants (tricyclics and SNRIs) and anticonvulsants (pregabalin, gabapentin, carbamazepine) are effective for neuropathic pain conditions like diabetic neuropathy and post-herpetic neuralgia. Interestingly, antidepressants can be effective for pain relief even in patients without depression, and at lower doses than used for depression treatment.
• Topical NSAIDs: For localized pain, such as knee osteoarthritis, topical NSAIDs may be preferred over oral NSAIDs, especially in older adults, to minimize systemic side effects.

Alt Text: Pain management doctor explaining non-opioid treatment options to a patient for chronic pain.

When are Opioids Considered?

Pain management doctors consider opioid therapy only when the anticipated benefits for both pain reduction and functional improvement are expected to outweigh the significant risks. If opioids are deemed necessary, they should always be used in conjunction with non-pharmacological and non-opioid pharmacologic therapies to enhance overall pain management and minimize reliance on opioids alone.

2. Setting Realistic Goals and Exit Strategies:

Before initiating opioid therapy, a critical step is establishing clear treatment goals with patients. This discussion should include realistic expectations for pain relief and functional improvement. Importantly, pain management doctors should also consider and discuss how opioid therapy will be discontinued if it proves ineffective or if risks outweigh benefits.

Opioid therapy should only continue if there is clinically meaningful improvement in both pain and function that demonstrably outweighs the risks to patient safety. The absence of long-term evidence supporting the benefits of opioid therapy for chronic pain, coupled with the well-documented risks of long-term use, necessitates a cautious and goal-oriented approach.

Defining Treatment Goals:

• Pain and Function Improvement: Goals should focus on tangible improvements in both pain levels and functional abilities. While complete pain elimination may not be realistic, significant pain reduction that enables improved daily function is a primary aim.
• Functional Goals: These can be patient-centered and specific, such as being able to walk for a certain duration, return to work part-time, or participate in family activities. Tracking progress towards these goals provides a practical measure of treatment success.
• Validated Instruments: Pain management doctors may use validated tools like the PEG (Pain, Enjoyment of life, General activity) Assessment Scale to objectively track patient outcomes and measure clinically meaningful improvement (often defined as a 30% improvement in pain and function scores).
• Addressing Co-morbidities: Depression, anxiety, and other psychological conditions frequently co-exist with chronic pain and can hinder pain management. Pain management plans should incorporate assessment and optimized treatment for these conditions.

The “Exit Strategy”:

Recognizing that predicting long-term opioid effectiveness for individual patients is challenging, pain management doctors must consider an “exit strategy” from the outset. This involves:

• Pre-defined Criteria for Discontinuation: Establishing criteria for opioid tapering and discontinuation if treatment goals are not met, if opioids are no longer needed, or if adverse events pose unacceptable risks.
• Open Communication: Having transparent discussions with patients about the plan for opioid therapy, including the conditions under which opioids will be tapered or discontinued, promotes patient understanding and shared decision-making.

By setting clear goals and planning for potential discontinuation, pain management doctors prioritize patient safety and ensure a responsible approach to opioid therapy.

3. Discussing Risks and Benefits with Patients:

Transparency and informed consent are paramount when considering opioid therapy. Pain management doctors have a responsibility to thoroughly discuss the known risks and realistic benefits of opioid therapy with patients both before starting and periodically during treatment. This conversation should also cover the responsibilities of both the patient and the clinician in managing opioid therapy safely.

Key Discussion Points:

• Realistic Benefit Expectations: It’s crucial to be explicit and realistic about what opioids can and cannot achieve. While opioids can provide short-term pain relief, there is limited evidence to support long-term pain improvement or functional gains. Complete pain relief is often unlikely.
• Focus on Functional Improvement: Emphasize that improved function, even with persistent pain, is a primary treatment goal.
• Serious Harms: Patients must be informed about the serious adverse effects of opioids, including potentially fatal respiratory depression and the risk of developing opioid use disorder, a serious, chronic condition.
• Common Side Effects: Discuss common side effects like constipation, dry mouth, nausea, drowsiness, confusion, tolerance, physical dependence, and withdrawal symptoms. Provide strategies for managing common side effects like constipation (hydration, fiber, activity, stool softeners/laxatives).
• Driving Safety: Advise patients about the potential impact of opioids on driving ability, especially when starting therapy, increasing doses, or combining opioids with other central nervous system depressants like benzodiazepines or alcohol.
• Dosage-Related Risks: Explain that the risks of opioid use disorder, respiratory depression, and overdose increase at higher dosages. Reinforce the importance of taking only the prescribed amount, not exceeding the dose or frequency.
• Drug Interactions: Review the heightened risks of respiratory depression when opioids are combined with benzodiazepines, sedatives, alcohol, illicit drugs, or other opioids.
• Risks to Others: Discuss the dangers of sharing opioids, intentional or unintentional, with household members or others, especially children, who are highly vulnerable to accidental ingestion and overdose. Emphasize secure storage (preferably locked) and safe disposal of unused medication.
• Periodic Reassessment: Highlight the importance of regular reassessments to evaluate ongoing benefits and risks and to consider opioid discontinuation or adjustments as needed.
• Risk Mitigation Strategies: Discuss planned risk reduction measures, including Prescription Drug Monitoring Program (PDMP) use and urine drug testing. Consider discussing naloxone for overdose reversal.
• Cognitive Limitations: Assess for cognitive limitations, particularly in older adults, that might impact medication management and involve caregivers in co-management if necessary.

Regularly revisiting these points, at least every three months, is vital to ensure the ongoing appropriateness and safety of opioid therapy.

Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

4. Immediate-Release Opioids are Preferred:

When initiating opioid therapy for chronic pain, pain management doctors should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) formulations.

ER/LA opioids include medications like methadone, transdermal fentanyl, and extended-release versions of oxycodone, morphine, and others. Studies have indicated a higher risk of overdose associated with initiating treatment with ER/LA opioids compared to immediate-release options. There is no evidence to suggest that ER/LA opioids are more effective or safer than immediate-release opioids for chronic pain or that they reduce the risk of misuse or addiction.

FDA Recommendations:

The FDA has emphasized that ER/LA opioids should be reserved for managing severe pain requiring daily, around-the-clock, long-term opioid treatment, only when alternative options (non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or inadequate. ER/LA opioids are not intended for “as needed” pain relief. Some ER/LA opioids are only appropriate for opioid-tolerant patients who have already been receiving substantial daily opioid doses for at least a week.

Considerations Regarding ER/LA Opioids:

• Dosage Escalation: Time-scheduled use of ER/LA opioids can lead to higher total daily opioid dosages compared to intermittent, as-needed immediate-release opioids.
• Breakthrough Pain: The safety and effectiveness of using immediate-release opioids for breakthrough pain in conjunction with ER/LA opioids for chronic pain (outside of cancer, palliative, or end-of-life care) are not well-established and may contribute to dose escalation.
• Abuse-Deterrent Formulations: While abuse-deterrent technologies aim to make manipulation of ER/LA opioids more difficult, they do not prevent abuse through oral intake, the most common route. “Abuse-deterrent” labeling does not eliminate abuse risk.

Specific ER/LA Opioids: Methadone and Transdermal Fentanyl:

• Methadone: Methadone has been linked to a disproportionate number of overdose deaths relative to its prescription frequency. It also carries risks of cardiac arrhythmias and QT prolongation. Its complex pharmacokinetics, including a long and variable half-life, make it particularly challenging to prescribe safely.
• Transdermal Fentanyl: Transdermal fentanyl absorption and pharmacodynamics are complex, with gradual serum concentration increases over 72 hours and variable absorption based on factors like external heat. Dosing in mcg/hour can also be confusing for patients.

Recommendations for ER/LA Opioid Use:

Pain management doctors generally agree:

• For opioid-naïve patients, ER/LA opioids should not be initiated.
• ER/LA opioids should be reserved for severe, continuous pain in patients already receiving daily immediate-release opioids for at least a week.
• When switching to an ER/LA opioid, dosage adjustments are crucial to account for incomplete opioid cross-tolerance.
• Caution is needed in patients with renal or hepatic dysfunction due to potential drug accumulation.
• Combining immediate-release and ER/LA opioids should generally be avoided due to increased risk and diminishing returns for chronic pain management.

When ER/LA opioids are necessary, choosing formulations with predictable pharmacokinetics is preferred to minimize overdose risk. Methadone and transdermal fentanyl require specialized knowledge and caution.

• Methadone should not be a first-line ER/LA opioid. Prescribing methadone for pain should only be considered by clinicians experienced with its risk profile and prepared for close patient monitoring, including QT prolongation risk assessment and ECG monitoring.
• Transdermal fentanyl requires specialized knowledge. Clinicians prescribing transdermal fentanyl should be thoroughly familiar with its dosing and absorption properties and able to educate patients effectively on its use.

5. Prescribing the Lowest Effective Dosage:

When initiating opioid therapy, pain management doctors should prescribe the lowest effective dosage. Caution is essential at any dosage level. Careful reassessment of individual benefits and risks is crucial when considering dosage increases to 50 morphine milligram equivalents (MME)/day or higher. Increasing dosage to 90 MME/day or more should be avoided unless carefully justified.

Evidence Regarding Dosage and Risk:

• Limited Benefit of High Doses: There is limited evidence supporting the benefits of high-dose opioids for chronic pain. Studies on dose escalation have not shown improved pain control or function with higher doses.
• Increased Harm with Higher Doses: Risks of serious harms, including motor vehicle injury, opioid use disorder, and overdose, escalate with increasing opioid dosages. Overdose risk increases significantly at dosages of 50 MME/day or more.

Dosage Recommendations:

• Start Low: Initiate opioids at the lowest effective dose, using product labeling as a guide for starting dosages and considering patient opioid tolerance.
• Caution in Vulnerable Populations: Exercise extra caution when initiating opioids in patients aged 65 and older and those with renal or hepatic insufficiency due to increased drug accumulation risk.
• Gradual Titration: Increase dosages cautiously and in small increments. Allow sufficient time between dose increases (potentially waiting at least five half-lives or a week, especially for methadone) to fully assess the effects of the previous dose.
• Re-evaluation at 50 MME/day: Before increasing to 50 MME/day, reassess treatment goals and whether opioid therapy is meeting the patient’s needs.
• Precautions at 50 MME/day and Above: Implement additional precautions at 50 MME/day or higher, including more frequent follow-up and considering naloxone prescription and overdose prevention education.
• Avoid or Justify 90 MME/day and Above: Avoid increasing to 90 MME/day or higher unless carefully justified based on individual benefit-risk assessment, considering diagnosis, incremental benefits vs. harms at higher doses, alternative treatments, and specialist consultation recommendations.
• Re-evaluate at 90 MME/day and Above: If pain and function do not improve at 90 MME/day or if dosage requirements escalate, discuss alternative pain management approaches, consider opioid tapering, and consult a pain specialist.
• State-Specific Guidelines: Be aware of state-level regulations and clinical protocols related to MME thresholds.

Managing Patients on High-Dose Opioids:

For patients already on high-dose opioids (90 MME/day or more), pain management doctors should:

• Offer Re-evaluation: Explain the increased overdose risk associated with higher doses in a non-judgmental way and offer to re-evaluate continued high-dose opioid therapy.
• Offer Tapering: Empathically discuss benefits and risks of continued high-dose therapy and offer to collaborate on a tapering plan.
• Slow Tapering: Recognize that long-term high-dose opioid users may require very slow tapers with pauses to accommodate to lower doses.
• Monitor for Co-morbidities: Be alert for anxiety, depression, and opioid use disorder that may emerge during tapering and arrange for management of these conditions.
• Establish Goals and Maximize Non-Opioid Treatments: Set goals for continued therapy, maximize non-pharmacologic and non-opioid treatments, and consider pain specialist consultation.

6. Acute Pain Management and the Transition to Chronic Use:

Long-term opioid use often originates from treatment for acute pain. When opioids are used for acute pain, pain management doctors should prescribe the lowest effective dose of immediate-release opioids and limit the quantity to the expected duration of pain severe enough to require opioids.

Duration Limits:

• Three Days or Less: Often sufficient for acute pain management.
• More Than Seven Days: Rarely needed for acute pain.

Acute Pain and Long-Term Opioid Use:

Studies show a link between opioid use for acute pain and subsequent long-term opioid use. Greater initial opioid exposure increases the risk of long-term use. Limiting the duration of opioid prescriptions for acute pain minimizes the risk of unintentional transition to chronic opioid use.

Minimizing Physical Dependence:

Physical dependence is an expected physiological response to opioid exposure beyond a few days. Limiting prescription duration also reduces the need for opioid tapering to prevent withdrawal symptoms.

Expert Consensus:

Pain management doctors generally agree:

• For acute pain requiring opioids, prescribe the lowest effective dose for the shortest duration necessary.
• A few days of opioid exposure significantly increases risks, and each day of unnecessary use increases physical dependence risk without added benefit.
• Shorter prescriptions minimize the number of pills available for diversion.

Practical Guidance for Acute Pain Prescribing:

• Lowest Effective Dose: Use product labeling as a starting point, adjusting based on pain severity and patient factors (renal/hepatic function).
• Short Duration: In most cases of acute pain not related to surgery or trauma, a 3-day supply or less is often sufficient. While some experts suggest a range of 3-7 days, a shorter duration is generally preferred in primary care settings.
• Re-evaluation for Prolonged Pain: For severe acute pain lasting longer than expected, re-evaluate the diagnosis and adjust management.
• Avoid “Just in Case” Prescriptions: Do not prescribe extra opioids “just in case” pain persists.
• No ER/LA Opioids for Acute Pain: Due to longer half-lives and duration of effects, ER/LA opioids are not appropriate for acute pain management.
• Non-Opioid Alternatives: Acute pain can often be effectively managed with non-opioid approaches.

7. Regularly Evaluating Benefits and Harms of Continued Therapy:

Pain management doctors should evaluate the benefits and harms of opioid therapy with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or after dose escalation. Ongoing therapy requires reassessment every 3 months or more frequently. If benefits no longer outweigh harms, optimizing other therapies and working with patients to taper or discontinue opioids is essential.

Rationale for Frequent Monitoring:

• Early Risk of Opioid Use Disorder: Continuing opioid therapy for 3 months significantly increases the risk of opioid use disorder. Earlier follow-up is crucial for prevention.
• ER/LA Opioid Risk: Overdose risk with ER/LA opioids may be particularly high in the first two weeks of treatment.
• Limited Long-Term Benefit: Patients not experiencing pain relief with opioids within a month are unlikely to benefit long-term.

Follow-Up Intervals:

• Initial Follow-up (1-4 Weeks): Essential after starting long-term opioid therapy or dose escalation. Consider shorter intervals within this range for ER/LA opioids or dosages of 50 MME/day or higher. For methadone initiation or dose increase, follow-up within 3 days is strongly recommended.
• Regular Reassessment (Every 3 Months or More Frequently): For all patients on long-term opioid therapy, including new patients already on opioids. More frequent reassessment is needed for patients at higher risk of opioid use disorder or overdose.

Assessment Components at Follow-up:

• Benefits: Evaluate function, pain control, and quality of life using tools like the PEG scale and patient-centered functional goals.
• Harms: Assess for common side effects (constipation, drowsiness) and early warning signs of serious problems (sedation, slurred speech, craving, uncontrolled use).
• Patient Preferences: Discuss patient preferences for continuing opioids based on perceived benefits and harms.

Actions Based on Reassessment:

• Sustained Improvement: If benefits outweigh risks and treatment goals are met, continue therapy with ongoing monitoring.
• Insufficient Benefit or Increased Risk: If meaningful improvement in pain and function is not sustained, risks outweigh benefits, patients request dose reduction/discontinuation, or warning signs of adverse events emerge, work with patients to taper or discontinue opioids.
• Optimize Non-Opioid Treatments: Maximize non-pharmacologic and non-opioid pharmacologic pain management approaches.
• Pain Specialist Consultation: Consider consulting a pain specialist for assistance with pain management.

Considerations for Tapering Opioids:

When reducing or discontinuing opioids, a slow and gradual taper is crucial to minimize withdrawal symptoms.

• Taper Rate: A reasonable starting point is reducing the weekly dosage by 10%-50% of the original dose. Slower tapers (e.g., 10% per month) may be better tolerated, especially for long-term users.
• Individualized Plans: Tapering plans should be individualized based on patient goals and concerns.
• Pauses and Slowdowns: Tapers may need to be paused or slowed down based on patient response.
• Success Definition: Progress in tapering is considered success.
• Extending Dosing Interval: Once the smallest available dose is reached, extend the interval between doses before stopping completely.
• Rapid Tapers: May be necessary in cases of severe adverse events like overdose, but ultrarapid detoxification under anesthesia is dangerous and should be avoided.
• Pregnancy: Tapering opioids during pregnancy requires specialized expertise due to risks to the pregnant patient and fetus.
• No Taper for Non-Users: Patients not taking opioids (including those diverting them) do not require tapering.
• Overdose Risk After Taper: Discuss increased overdose risk upon returning to a previously prescribed higher dose after tapering.
• Support During Tapering: Collaborate with mental health providers and specialists to optimize non-opioid pain management and provide psychosocial support for anxiety during tapering.
• Opioid Use Disorder: If opioid use disorder is suspected, offer or arrange treatment and consider naloxone.

Assessing Risk and Addressing Harms of Opioid Use

8. Evaluating and Mitigating Risk Factors for Opioid-Related Harms:

Before starting and periodically during opioid therapy, pain management doctors must evaluate risk factors for opioid-related harms. Management plans should incorporate strategies to mitigate these risks, including considering naloxone for patients with increased overdose risk factors.

Risk Factors to Consider:

While evidence is limited on how harms vary based on demographics or comorbidities, certain factors are recognized to increase susceptibility to opioid-associated harms:

• History of Overdose: Prior overdose significantly elevates future overdose risk.
• History of Substance Use Disorder: Substance use disorders increase the risk of opioid use disorder and overdose.
• Higher Opioid Dosages (≥50 MME/day): Dosages at or above this level are associated with increased risks.
• Concurrent Benzodiazepine Use: Combining opioids with benzodiazepines dramatically increases respiratory depression and overdose risk.

Strategies for Risk Mitigation:

• Naloxone Prescription: Consider offering naloxone to patients with risk factors like overdose history, substance use disorder history, high opioid dosages, or concurrent benzodiazepine use.
• Frequent Re-evaluation: Increase the frequency of patient follow-up (more often than every 3 months) for those with risk factors.
• Specialist Referral: Consider referral to pain and/or behavioral health specialists for high-risk patients.

Specific Patient Populations and Risk Considerations:

• Patients with Sleep-Disordered Breathing (Including Sleep Apnea): Avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing whenever possible. For mild cases, use careful monitoring and cautious dose titration.
• Pregnant Women: Opioid use during pregnancy carries risks for both mother and fetus, including stillbirth, poor fetal growth, preterm delivery, and neonatal opioid withdrawal syndrome. Careful benefit-risk assessment is crucial. Discuss family planning with women of reproductive age before starting opioid therapy. For pregnant women on opioids, tapering requires expert consultation due to fetal risks. Medication-assisted therapy (buprenorphine or methadone) is recommended for pregnant women with opioid use disorder.
• Patients with Renal or Hepatic Insufficiency: Use extra caution and increased monitoring due to reduced drug processing and excretion, leading to opioid accumulation and a narrowed therapeutic window.
• Patients Aged ≥65 Years: Older adults are more susceptible to opioid accumulation and have a smaller therapeutic window due to age-related physiological changes. They are also more likely to have co-morbidities and polypharmacy. Exercise extra caution and increase monitoring. Educate older adults on safe medication practices and implement falls risk assessment and prevention strategies.
• Patients with Mental Health Conditions: Patients with mental health conditions (depression, anxiety, PTSD) have an increased risk of opioid use disorder and overdose. Optimize treatment for mental health conditions. Consider behavioral health specialist consultation, especially for patients with suicide risk or psychiatric disorders. Avoid initiating opioid therapy during acute psychiatric instability. Be particularly cautious with benzodiazepine co-prescription in this population. Consider tricyclic or SNRI antidepressants for pain and depression if not contraindicated.
• Patients with Substance Use Disorder: Patients with drug or alcohol use disorders are at higher risk for opioid use disorder and overdose. Carefully weigh benefits and risks before prescribing opioids. Implement risk mitigation strategies, including naloxone and increased monitoring. Consider consulting substance use disorder and pain specialists. Communicate with patients’ substance use disorder treatment providers.
• Patients with Prior Nonfatal Overdose: Prior nonfatal overdose significantly increases the risk of future overdose. Work to reduce opioid dosage or discontinue opioids if possible. If opioid therapy continues, implement robust risk mitigation strategies, including naloxone and increased monitoring.

Offering Naloxone to Patients at Increased Risk:

Naloxone, an opioid antagonist, can reverse respiratory depression and save lives during an overdose. Consider offering naloxone to patients with risk factors for opioid-related harms.

Risk Factors Suggesting Naloxone Co-Prescription:

• History of overdose
• History of substance use disorder
• Concurrent benzodiazepine use
• Risk of returning to a high dose after a period of abstinence (e.g., post-incarceration)
• High opioid dosages (≥50 MME/day)

Provide education on overdose prevention and naloxone use to patients receiving naloxone and their household members.

9. Utilizing Prescription Drug Monitoring Programs (PDMPs):

Pain management doctors should review a patient’s history of controlled substance prescriptions using state PDMP data. PDMPs help identify patients receiving high opioid dosages or dangerous combinations that elevate overdose risk.

PDMP Review Recommendations:

• Frequency: Review PDMP data when starting opioid therapy for chronic pain and periodically during therapy, ranging from every prescription to every 3 months.
• Purpose: To identify patients receiving opioids from multiple prescribers, high total daily opioid dosages, or dangerous combinations (e.g., opioids and benzodiazepines).
• Benefits: PDMP data can be helpful when patient medication history is incomplete or when patients transition care.

Actions Based on PDMP Review:

If PDMP data reveals high opioid dosages, dangerous combinations, or multiple prescribers:

• Discuss PDMP Findings with Patient: Confirm patient awareness of all prescriptions and address any discrepancies.
• Discuss Safety Concerns: Explain increased risks of respiratory depression and overdose. Consider offering naloxone.
• Avoid Opioid-Benzodiazepine Co-prescription: Minimize concurrent prescribing whenever possible. Coordinate care with other prescribers to prioritize patient goals and weigh risks.
• Calculate Total MME/day: Assess overdose risk based on total opioid dosage. Consider tapering to safer dosages and offer naloxone if dosages are high.
• Communicate with Other Prescribers: Discuss safety concerns and coordinate care to improve patient safety.
• Consider Substance Use Disorder: Evaluate for potential substance use disorder.
• Urine Drug Testing: Consider urine drug testing to assess medication adherence and potential diversion.

Important Note: Do not dismiss patients from practice based solely on PDMP information. This can harm patient safety and miss opportunities for intervention and support.

10. Urine Drug Testing:

Pain management doctors should use urine drug testing before starting opioid therapy and consider it at least annually during therapy. Urine drug testing helps assess for prescribed medications, other controlled prescription drugs, and illicit drugs.

Purpose of Urine Drug Testing:

• Identify Unreported Drug Use: Detect concurrent use of opioids with other opioids, benzodiazepines, or heroin, which increases overdose risk.
• Assess Medication Adherence: Identify patients not taking prescribed opioids, which may indicate diversion or other clinical issues.

Limitations of Urine Drug Testing:

Urine drug tests do not quantify drug dosage or provide precise information about drug amounts consumed.

Recommendations for Urine Drug Testing:

• Before Starting Opioids: Use urine drug testing for baseline assessment.
• Periodically During Therapy (Consider Annually): Regular testing helps monitor for ongoing risks. Frequency can be adjusted based on individual patient risk factors.
• Standardized Policies: Routine testing with standardized clinic policies may help reduce stigma.

Urine Drug Testing Procedures:

• Initial Immunoassay Panel: Use a relatively inexpensive panel for common opioids and illicit drugs.
• Confirmatory Testing: Consider confirmatory testing (e.g., gas or liquid chromatography/mass spectrometry) when specific opioid detection is needed or for unexpected results.
• Panel Interpretation: Understand the drugs included in the testing panel and how to interpret results. Be aware of metabolite relationships (e.g., hydromorphone as a metabolite of hydrocodone).
• Test for Relevant Substances: Only test for substances where results will impact patient management. Clinical implications of some results (e.g., THC) may be unclear.
• Plan for Unexpected Results: Have a plan for responding to unexpected findings.
• Patient Communication: Explain the purpose of testing to improve safety and discuss expected results. Ask patients about their medication and drug use history.

Responding to Unexpected Results:

Use unexpected results to improve patient safety. Possible actions include:

• Adjust pain management strategy
• Taper or discontinue opioids
• Increase follow-up frequency
• Offer naloxone
• Refer for substance use disorder treatment

If tests repeatedly show negative results for prescribed opioids, consider discontinuing the prescription without tapering.

Do not dismiss patients from care based on urine drug test results. Focus on using results to improve patient safety and provide appropriate interventions.

11. Avoiding Concurrent Prescription of Opioids and Benzodiazepines:

Pain management doctors should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.

Rationale for Avoiding Co-prescription:

Both benzodiazepines and opioids are central nervous system depressants. Their combined use significantly increases the risk of respiratory depression and potentially fatal overdose. Concurrent benzodiazepine and opioid prescriptions have been linked to a near quadrupling of overdose death risk compared to opioid prescription alone.

Circumstances for Co-prescription:

While generally avoided, there may be rare situations where co-prescription is considered (e.g., severe acute pain in a patient on stable, low-dose benzodiazepines). In such cases, extreme caution and close monitoring are essential.

Managing Concurrent Prescriptions:

• Check PDMP: Review PDMP data for concurrent prescriptions from other clinicians.
• Pharmacist/Pain Specialist Consultation: Involve pharmacists and pain specialists in the management team when co-prescription is unavoidable.
• Prioritize Tapering Opioids First: Due to greater benzodiazepine withdrawal risks, tapering opioids first may be safer and more practical when both are being used.
• Gradual Benzodiazepine Taper: If benzodiazepine discontinuation is necessary, taper gradually (e.g., 25% reduction every 1-2 weeks) to prevent withdrawal complications. CBT can improve tapering success.
• Alternative Anxiety Treatments: If benzodiazepines are tapered or discontinued, offer evidence-based psychotherapies (CBT) and/or non-benzodiazepine medications for anxiety.
• Coordinate Care with Mental Health Professionals: Communicate with mental health providers to discuss patient needs, prioritize goals, weigh risks, and coordinate care.

12. Offering Evidence-Based Treatment for Opioid Use Disorder:

Pain management doctors should offer or arrange evidence-based treatment for patients with opioid use disorder. Medication-assisted treatment (MAT) with buprenorphine or methadone, combined with behavioral therapies, is the standard of care.

Opioid Use Disorder Definition:

Opioid use disorder is defined by the DSM-5 as a problematic pattern of opioid use leading to clinically significant impairment or distress.

Prevalence:

Opioid dependence prevalence among chronic pain patients on opioid therapy in primary care settings ranges from 3% to 26%.

Evidence-Based Treatment:

• Medication-Assisted Treatment (MAT): Opioid agonist or partial agonist treatment with methadone or buprenorphine is more effective than placebo or no medication in preventing relapse in opioid use disorder.
• Behavioral Therapies: Combining behavioral therapies with MAT can further reduce opioid misuse, improve treatment retention, and enhance compliance.
• Naltrexone: Oral or long-acting injectable naltrexone (an opioid antagonist) is another MAT option, particularly for highly motivated individuals.

Addressing Treatment Gaps:

Treatment capacity for opioid use disorder often does not meet community needs. Patient cost can also be a barrier to buprenorphine treatment due to limited insurance coverage. Pain management practices should identify and utilize community treatment resources and work to improve local treatment capacity.

Identifying and Managing Opioid Use Disorder:

• Suspect Opioid Use Disorder: If concerns arise based on patient behavior, PDMP data, or urine drug testing, discuss these concerns with the patient.
• Assess for Opioid Use Disorder: Use DSM-5 criteria to assess for opioid use disorder or refer to a substance use disorder specialist for assessment.
• Offer or Arrange Treatment: For patients meeting criteria for opioid use disorder, offer or arrange evidence-based treatment, typically MAT with buprenorphine or methadone and behavioral therapies. Naltrexone is another option. For pregnant women with opioid use disorder, MAT with buprenorphine (without naloxone) or methadone is recommended.
• Naloxone for Overdose Prevention: Consider offering naloxone to patients with opioid use disorder.
• Tapering for Problematic Use (Without OUD): For patients with problematic opioid use that does not meet OUD criteria, offer opioid tapering. If tapering is unsuccessful, reassess for OUD and offer MAT if appropriate.

Physician Training and Resources:

Physicians not certified to prescribe buprenorphine can obtain training and a waiver from SAMHSA. Physicians prescribing opioids in communities with limited treatment capacity should strongly consider obtaining this waiver. Naltrexone prescription does not require a waiver.

Care Coordination and Ongoing Management:

Pain management doctors should:

• Assist patients in finding qualified treatment providers (SAMHSA resources are available).
• Arrange for patient follow-up with treatment providers.
• Ensure ongoing care coordination.
• Not dismiss patients from practice due to substance use disorder. OUD identification is an opportunity for intervention.
• Continue to provide pain management: Patients with co-occurring pain and substance use disorder require ongoing pain management, prioritizing non-pharmacologic and non-opioid treatments and considering pain specialist consultation.

By adhering to these recommendations, pain management doctors can provide effective and responsible care for patients with chronic pain, carefully considering the role of narcotics and prioritizing patient safety and well-being.