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Chronic Opioid Rules
Randall Lee Oliver, MD; April Taylor, RN
Posted: April 2005
Practical Pain Management; Mar/Apr 2003
Opioids are potentially dangerous medications that can
lead to accidental overdose, death, or impairment around machinery,
or while driving an automobile. Therefore -- even for the chronic
pain patients who generally need opioids to improve functionality --
they should be used judiciously and wisely.
Rule No. 1: There should be a single prescribing
physician using a multidisciplinary approach to pain management.
Dosages must be monitored and re-evaluated with monthly visits and,
because there is only one managing physician, the risk of overdose
and withdrawal is eliminated.
Rule No. 2: Complete a thorough history and
physical. Releases should be signed for any previous providers
regarding previous treating doctors and/or substance treatment
and/or psychological evaluations. Before a physician prescribes
a chronic opioid, the patient must have failed first line
treatments. Chronic opioid use is not appropriate until
non-opioid options have been tried and found inadequate. These
include NSAIDs, Ultram, trigger-point injections, physical therapy,
and chiropractic care. Documentation of this failure must be shown.
Rule # 3: Perform urine drug screens on
Rule # 4: Make appropriate consults; share
the responsibility of treatment of the chronic pain syndrome.
Since most chronic pain patients will eventually develop severe
depression and/or anxiety as part of the syndrome, psychological
care must be addressed as part of the overall treatment of chronic
Rule # 5: Co-morbid conditions must be identified
and treated. Pain cannot be controlled unless the co-morbid
conditions of fatigue, insomnia, sexual dysfunction, anxiety and
depression are also controlled.
Rule # 6: Monthly visits with accompanying
documentation of symptoms and improvement of function is necessary
to show continued need for the opioids. Constant re-evaluation for
success and monitoring for warning signs of addiction or abuse is an
Rule # 7: A signed contract or opioid agreement
should be on file. The contract must easily and completely describe
the risks and benefits of opioid use. Consequences for
non-compliance is key. Only give opioids to patients who follow
Rule # 8: Use long-acting opioids for chronic pain
and avoid the short-acting opioids -- except for breakthrough pain.
Avoid mixing long-acting opioids with other long-acting opioids and,
likewise, short-acting opioids with other short- acting opioids.
Rule # 9: When prescribing long-acting opioids,
the dose should be determined by the maximum effective dose, not the
maximum tolerated dose. Maximum tolerated dose would be infinite
because you can gradually work up to any dose. Maximum effective dose
is the dose that gives the maximum functionality while recognizing
that relief in a chronic pain patient is not a totally pain-free state.
Rule # 10: Do not prescribe opioids to drug
abusers. A drug addict has no ability to control himself when narcotics
Summary: Each patient needs to be monitored closely for
risks and benefits and reevaluated at every visit for the continued need
of opioid therapy.