Safe Opioid Prescribing Practices: Knowing When to Prescribe, Taper, or Discontinue
Decisions about increasing or tapering opioid dosages require a multifactorial approach.
LAS VEGAS—In 2008, drug poisonings overtook motor vehicle accidents as the number 1 cause of accidental deaths in the United States.1 That statistic serves to reinforce the need to advise patients about safe opioid use and storage, according to a presentation at PAINWeek 2016.2
John A. Hopper, MD, a clinical professor at Wayne State University School of Medicine, discussed safe opioid prescribing practices during the meeting.
When considering prescribing opioids to a patient, Dr Hopper first asks himself if this is the right diagnosis for opioids. “You should ask yourself, should I use opioids for this, and you base this on your own scope of practice, as well as what the guidelines tell you to follow," Dr Hopper said.
Dr Hopper said he then considers “is this the right brain,” for opioids, as in, is it safe to give this particular treatment to this particular patient?
“The final piece that helps me [make a decision whether to prescribe an opioid] is to consider if this is a patient who can take this drug home and safely manage this in the home,” Dr Hopper said.
After a patient is prescribed opioids, the next step is to monitor how the patient is doing on the medication through continued evaluation.
“When a patient isn't doing well from a pain management standpoint, we need to look at that,” Dr Hopper advised. “Always temper suspicion with mercy. You have to consider if this patient is seeking pain relief, is there disease progression, does this patient have unrealistic expectations … or, are they seeking drugs to deal with an addiction and/or entrepreneurship?”
Decisions about increasing opioid dosage or frequency, or tapering can be facilitated through physical examinations, discussions with the patient, urine testing, and referring to what the guidelines advise, Dr Hopper explained.
“Another point in terms of safety, is the patient safety agreement, which is critical in that it helps you stratify risk,” Dr Hopper advised.
Dr Hopper called knowing when to taper opioids a “critical skill,” and said that this process must be done carefully by identifying a lack of benefit and the potential for harm, assessing urgency of withdrawal symptoms, and tapering opioids while also managing withdrawal symptoms.
“When you are discontinuing opioids, you need to discuss with the patient the withdrawal risks. [Explain] how you are going to manage it, explain alternatives, and where necessary, consider diagnosis of substance abuse,” he said. “Think about screening, a brief intervention, and referral to treatment, when necessary.”
1. CDC. QuickStats: death rates for three selected causes of injury—National Vital Statistics System, United States, 1979–2012. MMWR. 2014;63(46):1095.
2. Hopper J. The need for a personalized team approach in managing chronic pain. Presented at PAINWeek 2016; Las Vegas, NV: September 6-10, 2016.