11th Commandment: Thou Shalt Not Prescribe Short-Acting Opioids for Chronic Pain!
Pain clinicians and scientists worldwide have come to recognize that chronic pain is a disease of the central nervous system resulting from nerve cell reconfiguration known as neuroplasticity. In essence, chronic pain (generally defined as pain lasting 6 months or longer; not consistent with the normal healing processes, potential unidentifiable pathology, and decreased function) is a disease that in many ways is similar to other chronic disorders. Why then do we treat it differently when prescribing medication, especially opioids?
No matter how you slice it, all immediate release (IR) opioids have a short half-life which averages around 4 hours. The translation is that a person taking IR opioids should not expect pain relief for greater than 3-6 hours per dose. Comparatively speaking, imagine prescribing an antihypertensive that lasts 4 hours, the patient is to measure the BP each 4 hours, and with a pressure exceeding certain parameters, “pop a pill”.
Hydrocodone/APAP 5/500mg, Take 1-2 tablets PO Q4-6H PRN pain. This is the typical pain prescription.
According to a recent interview with Dr. Steve Passik, “…8.8 million people are on chronic opioid therapy and 5.5 million of them are on hydrocodone. Now, putting aside the fact that hydrocodone and other short acting opioids are not considered right for every person along the spectrum of pain and risk for addiction, could we possibly be doing things right if more than 60 some odd percent of patients are on the same drug?”.
Imagine for a minute that you are the patient. You’re already feeling embarrassed and shady because the prescriber questions you, the pharmacist questions you, and really, you don’t want to be dependent on these drugs for intractable pain anyway…you would rather not have pain! You go to bed at night, take one tablet; after three hours of tossing and turning you take another; 3 hours later you wake up…can I take one tablet, has enough time gone by to take two tablets, I need to sleep because of a job interview tomorrow, etc. This cycle goes on for a month taking short-acting opioids throughout the day, an extra for walking the dogs, grocery shopping, cutting the lawn. Now it’s Friday afternoon on Labor Day weekend, and “just two tablets left”. You are in a panic, your doctor doesn’t want to speak with you at the nth hour regarding a hydrocodone refill on the Friday before a holiday weekend, and so the story goes. Who is really at fault here; is it the patient or the prescriber?
By way of example, the following is a partial list of hyperlipidemia risk factors in a patient receiving statins:
- Smoking
- High-fat/high-cholesterol diet
- Obesity
- Lack of physical activity
- Age and gender (Male)
- Age and Gender (Female)
- Liver disease
- High blood pressure due to sedentary lifestyle
- Family history of [heart disease]
What are some risk factors associated with chronic acetaminophen-containing short-acting opioids?
- See above, substitute [heart disease] with [substance abuse]
But do we ask these questions to our chronic pain patients?
I liken short-acting PRN chronic opioids to the following:
- Regular insulin 2U SQ Q4-6H PRN for high sugar (glucose test not necessary); see you in 6 months.
- Dopamine 500mg 1-2 tabs PO Q4-6H PRN for Parkinson rigidity, frequent falls and drooling; see you in 6 months.
- Warfarin 5mg PO Q4H PRN for atrial fib (INR not necessary); see you in 6 months
- Nifedipine 10mg 1-2 PO Q4-6H PRN if you think your BP is high (no monitoring necessary); see you in 6 months
- Simvastatin 20mg 1-3 tablets PO daily PRN for anticipated high cholesterol, depending on meals (no LFTs or lipid monitoring necessary); see you in 6 months
Chronic opioids for chronic pain should include extended release formulations, initial risk stratification (similar to diet, exercise, baseline LFTs & lipids with ongoing monitoring for statins), functional assessment, baseline urine analysis, controlled substance agreement, counseling if indicated, occasional serum monitoring, physical therapy, attempt at healthy lifestyle, monitoring of functional improvement, etc.
You don’t have time to do these things in your practice? Do you have time to treat diabetes, depression, hypercholesterolemia, sleep disorders, hypertension, and more? Unless we are prepared to pay specialists for every disorder, a new model needs to be established that encourages and assists primary care providers in the treatment of chronic pain disorders.
Chronic, short-acting, as needed opioids prescribed regularly without continuous thoughtful monitoring are counter-intuitive. Are chronic opioids only appropriate for cancer pain as suggested by some adversaries? No… Why you ask? We are all terminal, but some of us are more terminal than others.
Enjoy your holiday weekends, and as always, comments are welcome!
Fortunately or unfortunately, we live in a world of instant gratification. Everyone wants to receive their desires immediately. Unfortunately for chronic pain and most every other common condition such as hypertension, hyperlipidemia, and diabetes, we don’t have a quick cure. What we do have, however, are medication that MANAGE these diseases. Managing a disease means that we as healthcare professionals need to continuously monitor and assess these patients to make sure we are properly treating them.
Dr. Fudin’s scenario described above is just another presentation of a lack of understanding and management that exists for short acting opioid medications. How much blame can we really put on the patient for taking these medications as they are prescribed? Most patients that seek out the help of medical professionals come because they trust in us; we have a duty to “first, do no harm.” By carelessly prescribing and dispensing short acting opioids we are creating our own worst nightmare. By carelessly prescribing and dispensing these substances we may increase the likelihood of abuse and addiction. Proper monitoring and assessment of these patients before and during treatment will take us a long way in combating the poor stigma that’s associated with this specific drug class, and opioids as a whole.
PROP seeks to do this by changing the labeling of opioids, what I believe is another attempt at a quick fix for a multi-dimensional problem. They believe that limiting the approved indications of opioids and placing a time and dosage cap on their usage is going to solve the problem of overprescribing. They do not even address the importance of professional education, and will leave multitudes of patients with non-cancer pain to suffer unnecessarily. It’s almost insulting to think that PROP feels that medical professionals are so incompetent in the prescription of opioids that they are no longer going to allow us to use our medical judgment in prescribing and dispensing these prescriptions. The answer is not limiting the prescribed use of these drugs or prescribing them off-label, but instead eliminating the lack of proper understanding that surrounds them. Opioids can be a wonderful drug for patients that suffer from moderate to severe pain in which other medication classes are either contraindicated or offer minimal or no relief. As we all know, however, they can also be drugs that lead to devastating consequences if not used properly. These drugs should be respected by prescribers, pharmacists, and patients. The first step to respecting these substances requires proper professional education and diligence; in both the doctor’s office and each side of the pharmacy counter.
Comical, but so true!! It seems our patients requiring pain management have little, if any, follow-up. These are the only patients that are not being asked “How is it working?” and “How do you feel?”. From the pharmacists’ point-of-view early refills come across as abuse, we should recognize this as a potentially failed drug regimen for a patient in pain. -Justine
Thank you Dr. Marryott. It’s always enlightening to see your comments here. Keep up the good work in Florida and patient advocacy!