When Opioids Fail in Primary Care

When high blood pressure is treated, a patient is educated and a medication is prescribed. After a certain amount of time, the outcome of the treatment is evaluated.

If the goal of the treatment is not met, it is not common practice to continue increasing the dose of the medication until the target is achieved. Instead, many factors are taken into consideration, such as medication treatment alternatives, adherence, resistance, family history, and lifestyle. At this point, a new treatment plan and goal are defined, which may include a referral to a cardiac specialist.

But when community pharmacists are filling prescriptions for patients treated for chronic pain in the primary care setting, it appears that the dose is increased when the goal of treatment is not met.

This increased dose may temporarily meet the patient’s initial goal of pain control for a few months; however, the dose is then increased again. This process appears to take place regardless of the side effects that the patient may be experiencing or the patient's risk abuse profile.

Ideally, there is a simple and direct process that health care providers should follow when prescribing prescription opiates.

First, the prescriber and patient come to the conclusion that opiates are necessary for this particular pain. Next, the best alternative for this specific patient is prescribed and implemented. Finally, the outcome of therapy is evaluated and a decision is made as to whether the goals were accomplished.

After the prescriber concludes that the patient’s pain is not being controlled by non-opiate measures and considers that the moderate to severe pain is significantly impacting quality of life, a well-measured decision may conclude that opiate therapy is necessary.

Prior to dispensing a prescription opiate medication to a patient, the process of identifying the patient's risk for opiate abuse is an important yet widely underused tool. Does the patient have any family or personal history of substance abuse, mental health issues, or any other high-risk activities that may increase the potential for abuse?

Setting clearly defined goals of therapy with the patient as well as specific conditions of treatment will help strengthen the relationship from the beginning. Specifically, what improved quality of life indicators are we looking to achieve and how exactly will we measure them?

A written or verbal agreement that the patient will see only 1 physician and 1 pharmacy for their opiate pain treatment is another necessary step. Of course, the physician, patient, and pharmacy will all understand that this agreement will be verified on a regular basis through the Controlled Substance Utilization Review and Evaluation System (CURES).

In order to be complete, this agreement will also address the conditions that will warrant termination of the pain treatment agreement. These conditions may include the inability to reach the mutually agreed upon quality of life indicators, side effects that are persistent or intolerable, or behaviors by the patient that breach the 1 physician, 1 pharmacy agreement.

An acceptable initial outcome of therapy after the 2-month titration period would involve an evaluation of the goals that were outlined in the patient’s agreement with the physician. Has the treatment provided an acceptable level of pain control in relation to the quality of life indicators initially identified? Is the patient experiencing an acceptable level of side effects from the medication, and is the patient following through on appropriate and acceptable dosing?

If the answers to all of the above are yes, then the outcome of therapy is acceptable. The patient and physician may now look toward the next goal evaluation 2 to 3 months in the future.

On the other hand, opiate failure may present in many ways.

If the patient is still unable to meet quality of life indicators after 2 months of opiate titration, then a referral to a pain specialty clinic is warranted. Secondarily, if the patient has met quality of life indicators, but is experiencing an intolerable amount of opiate-induced side effects, then an evaluation of the current treatment regimen is warranted.

Finally, if the patient is displaying aberrant behaviors, such as early refill requests, identification of other prescribers or pharmacies, substance misuse or abuse, or addictive behaviors, then the pain agreement has been breached. At this point, it is important to follow the plan specified in the initial agreement in order to maintain consistency and continuity of care.

The initial agreement may have dictated that the patient gets 1 or even 2 chances, immediate termination from practice, referral to a pain clinic or any number of other plans. The important point is that there is an agreement to refer back to that coincides with a mutually agreed upon plan to implement action.

Similar to psychiatry, dermatology, cardiology, and any other medical specialties, the treatment of chronic pain is a specialty practice. When opiate failure occurs in the primary care setting, patients would do well to be referred to a pain specialist.