Chronic Narcotic Guideline

See Also

Contraindications
Relative

Substance Abuse (especially Narcotic Abuse)
Severe character pathology or Personality Disorder
Chaotic social environment

Adverse Effects

Cardiovascular events (including sudden death)
1. QT Prolongation occurs most commonly with Methadone, Buprenorphine, Oxycodone
2. Avoid combining with other agents that potentiate Arrhythmia risk (e.g. Methadone and Diazepam)
Constipation and Abdominal Pain
1. See Opioid Induced Constipation
Major Depression and Suicidality Risk
1. Major Depression risk increases 25% with use >90 days and 50% with use >180 days
  1. Scherrer (2014) J Gen Intern Med 29(3):491-9 +PMID:24165926 [PubMed]
2. Avoid combining Opioids with other CNS Depressants
3. Limit Opioid dosing and quantity with appropriate follow-up
4. Monitor for aggression and impulsivity (Suicidality risks)
5. Encourage mental health referral (also beneficial in Chronic Pain Management)
6. Use Antidepressants as appropriate, but avoid agents with risk in Overdose (e.g. Tricyclic Antidepressants)
Hypothalamic-Pituitary hypofunction
1. Decreases gonadal Hormones including Testosterone
2. Consider obtaining Hormone levels prior to initiating Chronic Opioids
3. Buprenorphine has less Hormone suppression than Methadone
4. Hormonal levels improve on tapering Opioid dose
5. Rhodin (2010) Clin J Pain 26(5):374-80 +PMID:20473043 [PubMed]
Opioid-Induced Hyperalgesia
1. Opioids may paradoxically worsen pain, and increase pain sensitivity with chronic use
2. Taper dose and re-evaluate after Opioid Withdrawal completed at 2-4 weeks
Opioid Misuse and abuse
1. See Complications below
2. Refer to pain management
3. Refer to Chemical Dependency
4. Naloxone prescription for home (for emergency prn use)
5. Suboxone is less likely to be misused or abused (but can still be abused via snorting or IV)
Opioid Dependence and tolerance
1. Taper Opioids
2. Treat Opioid Withdrawal with non-controlled substances (e.g. Antiemetics, Muscle relaxants, Clonidine)
3. Do not exceed >120 mg/day of total Morphine Equivalents
  1. CDC recommends limiting Opioids to 90 mg/day of total Morphine Equivalents in non-Cancer Pain
4. Involve pain management to consider transition to other agents or tapering medication
Opioid Overdose and apnea risk
1. Limit or taper Opioids if comorbid apnea risk (Sleep Apnea, binge drinking or excessive Alcohol use)
2. Avoid combining CNS Depressants (e.g. Benzodiazepines)
3. Caution patients not to cut patches, crush or chew long-acting Opioids (and other misuse)
4. Naloxone prescription for home (for emergency prn use)

Complications

Overdose Risk Factors
1. Sleep Apnea
2. Congestive Heart Failure
3. Lung disease
4. Sedative-Hypnotics (e.g. Benzodiazepines)
5. Problem Alcohol use
6. Comorbid psychiatric illness (e.g. Major Depression)
Opioid misuse or Opioid Use Disorder Risk Factors
1. See Opioid Risk Tool
2. Narcotic Seeking Behavior
3. Personal or Family History of Substance Abuse
4. Psychiatric comorbidity
5. Preadolescent history of sexual abuse

Guidelines
Chronic Opioid Use Guidelines in Non-Cancer Chronic Pain

Observe for Narcotic Seeking Behavior
1. See Prescription Drug Monitoring Programs link below
Avoid confusing Pseudo-addiction for addiction
1. Avoid inadequate treatment of pain
Single clinician should primarily manage patient
Incorporate Narcotic Contract consistently (renew annually)
Maintain Narcotic use flow sheet
Titrate to pain relief and adverse effects
1. Reevaluate on a 1-4 week basis
Documentation is key (see follow-up below)
Convert short-acting Opioids to long-acting Opioids
1. Use long-acting Narcotics around the clock
2. Use short-acting Narcotics for breakthrough pain
  1. Prescribe only a relatively small number of short acting doses per month (e.g. 10 per month)
Use in combination with other therapy
1. See Chronic Pain Management
2. Non-Opioid Analgesics
3. Make use of non-pharmacologic modalities
Treat Opioid Adverse Effects prophylactically
1. See Bowel Regimen in Chronic Narcotic Use
Be aware of pseudotolerance
1. Opioid appears to fail to control pain
2. Pain flares are countered with escalated dosing and not returning to prior baseline
3. Set expectations with patient
  1. Medication returns to prior baseline after brief flare
  2. Unauthorized dosage increases are not allowed

Protocol
Initial Assessment for non-cancer pain Chronic Opioid therapy

Select appropriate patients for Chronic Opioids
1. Screen patients for Opioid misuse or Opioid Abuse
2. See DIRE Score
3. See Opioid Risk Tool
4. Ask CAGE Questions
Select appropriate conditions for Chronic Opioids
1. Opioid responsive conditions (partially)
  1. Musculoskeletal pain
  2. Peripheral Neuropathy
  3. Postherpetic Neuralgia
2. Opioid poorly responsive conditions (visceral pain, central pain)
  1. Chronic Abdominal Pain
  2. Chronic Pelvic Pain
  3. Fibromyalgia
  4. Headaches
Select appropriate agent
1. Start with short-acting Opioids
2. MS Contin (Morphine long acting)
  1. Preferred
  2. Avoid in Renal Failure
3. Oxycontin (Oxycodone long acting)
  1. High abuse potential
4. Transdermal Fentanyl
  1. Expensive, risk of tolerance, variable absorption
5. Methadone
  1. Very effective, with less tolerance risk and inexpensive
  2. Do not prescribe to patients at risk for Overdose (increased risk of death)
    1. Ray (2015) JAMA Intern Med 175(3):420-7 [PubMed]
  3. Requires knowledgable prescriber familiar with agent
  4. Risk of QT Prolongation
6. Buprenorphine (transdermal or combined with Naloxone in Suboxone SL)
  1. Effective Analgesic with lower tolerance risk and lower abuse risk
  2. Requires special prescriber training, and is expensive
Complete prerequisites at initial visit
1. Controlled Medication Agreement (Narcotic Contract)
2. Urine Drug Screen
Educate regarding expectations
1. Review pain control expectations
  1. Expect a 20% pain reduction at best
  2. See Chronic Pain Management
2. Review escalating and tapering the dose
3. Review rules and protocol when non-compliant
Review Chronic Pain Flare Management
1. Flares are same pain type and same location with an increase in intensity

Protocol
Follow-up Visits

Schedule follow-ups
1. Initial: Reevaluate on a 1-4 week basis
2. Later: Reevaluate every 3 months
Documentation: 4A's
1. Analgesia
  1. Document pain level (scale of 1 to 10)
2. Adverse Effects
  1. Document Opioid side effects (e.g. Constipation, Nausea or Vomiting, sedation)
3. Activity Level
  1. Document functional status
  2. Following regular Exercise?
    1. See Exercise in Chronic Pain
4. Adherence
  1. Annually renew Controlled Medication Agreement (Narcotic Contract)
  2. Document compliance with prescribed therapy (see pill counts below)
  3. Last physical therapy visit
  4. Last mental health provider visit
Documentation: Comorbidity
1. Major Depression (consider PHQ-9)
2. Anxiety Disorder (consider GAD-7)
3. Sleep Disorders
4. Pregnancy
Monitoring
1. Urine Drug Screen
2. Pill Counts
  1. Patient should bring pill bottles to each visit
3. Reassess DIRE Score
Stopping or tapering Opioid therapy
1. See indications below
2. For a compliant patient without drug misuse, but without benefit at higher dose Opioid
  1. Consider supplying patient with short acting agents for breakthrough pain on titration
  2. Consider supplying patient with smaller increment doses of total daily dose
    1. Supply four 15 mg ER in place of each 60 mg ER
3. For a noncompliant patient (rapid taper)
  1. Print the following taper (or similar) for the patient to follow
  2. First, discontinue the long acting agent immediately (do not refill)
  3. Then taper frequency and dose of short-acting agent
    1. Example for patient on 80 mg of short acting Oxycodone 5mg (taper with #68 tabs)
    2. Oxycodone 10 mg every 3 hours for 2 days (#32 of 5 mg tabs)
    3. Oxycodone 10 mg every 4 hours for 1 day (#12 of 5 mg tabs)
    4. Oxycodone 10 mg every 6 hours for 1 day (#8 of 5 mg tabs)
    5. Oxycodone 10 mg every 8 hours for 1 day (#6 of 5 mg tabs)
    6. Oxycodone 5 mg every 8 hours for 2 days (#6 of 5 mg tabs)
    7. Oxycodone 5 mg every 12 hours for 1 day (#2 of 5 mg tabs)
    8. Oxycodone 5 mg daily for 2 days (#2 of 5 mg tabs)
    9. Stop medication
  4. Reference
    1. Gazelka (2017) How to get your difficult patients off Opioids, Mayo Clinical Reviews, Rochester, MN
4. For a patient with misuse (addiction, diversion)
  1. Stop all Opioids immediately and no refills

Protocol
Stopping or tapering Chronic Opioids

See Opioid Withdrawal
General indications to stop or taper Opioids
1. DIRE Score falls below 14
2. Marginal pain control or decreasing function (or lack of improvement with Opioid)
3. Non-compliance with prescriptions or with self-care
Tapering Opioids to lower doses may improve quality of life and function
1. Pain often does not worsen despite decreasing dose
Indications to immediately stop Chronic Opioids
1. Threatening or aggressive behavior toward clinic staff or provider
2. Confirmed diversion, prescription forgery, or obtaining Opioids from multiple sources
3. Confirmed Illicit Drug use (including Marijuana)
Indications to rapidly taper Chronic Opioids (10-20% weekly)
1. Repeated early refill requests despite adequate titration of long-acting Opioids
2. Intoxication or serious adverse effects (e.g. Altered Level of Consciousness)
3. Opioid-Induced Hyperalgesia
4. Broken Controlled Substance Agreement
Indications to gradually taper Chronic Opioids (5-10% every 2 to 4 weeks; no more often than every week)
1. Morphine Equivalent dose >100 mg/day without clear improvement in pain or function
2. Persistent significant adverse effects despite Opioid rotation
3. Functional goals not met
  1. Less than 30% improvement in daily activities or pain severity from time of starting Opioids
  2. Less than 30% improvement in daily activities or pain severity from time of last increase in dose
Anticipatory Guidance (what to expect with withdrawal)
1. See Opioid Withdrawal
2. Opioid Withdrawal is uncomfortable, but not life threatening (unlike Alcohol and Benzodiazepines)

Resources

Prescription Drug Monitoring Programs (alliance of states sites)
1. http://www.pmpalliance.org/content/pmp-access

References

(2015) Presc Lett 22(12):68
(2014) Presc Lett 21(12): 67
Sokolove (2001) CMEA Medicine Lecture, San Diego
Lembke (2016) Am Fam Physician 93(12): 982-90 [PubMed]
Berland (2012) Am Fam Physician 86(3): 252-8 [PubMed]