How can healthcare providers mitigate opioid use and address overprescribed narcotics in pain management?

Mitigating Opioid Use and Promoting Alternative Pain Management Approaches

Nonopioid therapies should be maximized as first-line treatment for subacute and chronic pain, with opioids considered only when expected benefits for pain and function outweigh risks to the patient. 1

Evidence-Based Strategies for Reducing Opioid Prescribing

Patient Risk Assessment and Education

• Perform thorough risk assessment before prescribing opioids:

  • Use validated screening tools like Drug Abuse Screening Test (DAST) and Alcohol Use Disorders Identification Test (AUDIT) 1
  • Ask direct questions about past substance use: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" 1
  • Check Prescription Drug Monitoring Program (PDMP) data to identify potential doctor shopping 1

• Provide comprehensive patient education:

  • Discuss realistic benefits and known risks of opioid therapy 1
  • Explain that pain management goal is to make pain manageable rather than eliminate it completely 1
  • Emphasize increased risks of respiratory depression when opioids are combined with benzodiazepines, other sedatives, or alcohol 1, 2
  • Educate about safe storage and disposal of medications 1

Implementing Alternative Pain Management Approaches

• Recommend evidence-based nonpharmacologic approaches:

  • Exercise therapy for back pain, fibromyalgia, and osteoarthritis
  • Weight loss for knee osteoarthritis
  • Manual therapies for hip osteoarthritis
  • Psychological therapy, mindfulness-based stress reduction, yoga, and acupuncture for low back pain
  • Cognitive behavioral therapy for fibromyalgia 1

• Utilize multimodal nonopioid pharmacologic options:

  • Acetaminophen and NSAIDs as foundation therapy 3
  • Adjunct medications like α2 agonists, NMDA receptor antagonists, muscle relaxants, and local anesthetics 3
  • For migraines specifically: triptans, NSAIDs, dihydroergotamine, and ergotamine plus caffeine 1

Strategies for Healthcare Systems and Providers

Changing Prescribing Practices

• Implement opioid prescribing and dispensing policies:

  • Avoid doses greater than 90-200 mg morphine equivalents per day 1
  • Limit initial prescription quantities 4
  • Avoid combination of opioids with benzodiazepines and carisoprodol 4
  • Reduce prescribing of long-acting/extended-release opioids 4

• Use opioid patient-provider agreements (PPAs) that include:

  • Informed consent component
  • Clear plan of care
  • Expectations for follow-up and monitoring 1

Monitoring and Risk Mitigation

• Conduct routine monitoring of patients on opioid therapy:

  • Implement urine drug testing (UDT) protocols 1
  • Perform periodic pill counts 1
  • Use prescription drug monitoring programs 1

• Consider naloxone prescriptions for high-risk patients:

  • Those with history of overdose
  • Patients with substance use disorders
  • Patients taking benzodiazepines with opioids 1

Convincing Reluctant Stakeholders

For Patients Resistant to Alternative Approaches

• Frame discussions around quality of life and function rather than just pain intensity
• Emphasize that opioids often become less effective over time due to tolerance
• Discuss opioid-related side effects that can worsen quality of life (constipation, nausea, cognitive effects)
• Share evidence that multimodal approaches often provide better long-term outcomes 3
• Use motivational interviewing techniques to address resistance

For Prescribers Resistant to Change

• Present evidence that comprehensive pain management systems reduce opioid prescribing while improving pain control 4, 5
• Highlight that 82% of clinicians report reluctance to prescribe opioids, suggesting awareness of risks 1
• Share success stories like the 95% reduction in brand name opioid-acetaminophen products achieved by Kaiser Permanente Southern California 4
• Emphasize that multimodal protocols have shown improved pain scores while reducing opioid use 5

Special Considerations

For Patients Already on Opioid Therapy

• Don't abruptly discontinue opioids in patients physically dependent on them
• Gradually taper doses when risks outweigh benefits
• Provide emotional support, close monitoring, and reassessment during tapering 1
• Link patients to addiction treatment and mental health services when indicated 1

For Patients with History of Substance Use Disorder

• Apply a universal precautions approach that views controlled substances as medications with unique risks to every patient 1
• Consider consultation with substance use disorder specialists and pain specialists 1
• For patients on medication-assisted treatment (methadone/buprenorphine):
  • Continue maintenance dose of opioid agonist therapy
  • Use short-acting opioid analgesics if needed for acute pain
  • Verify doses with treatment program 1

Common Pitfalls to Avoid

• Equating requests for pain medication with drug-seeking behavior
• Failing to address underlying anxiety about pain management
• Abruptly discontinuing opioids in physically dependent patients
• Relying solely on opioid contracts without providing alternative pain management options
• Using urine drug test results in isolation to discharge patients from care 1
• Neglecting to consider how cultural factors may influence pain expression and treatment preferences

By implementing these evidence-based strategies, healthcare providers can effectively mitigate opioid use while ensuring adequate pain management for patients with chronic pain conditions.