Updates in Prescribing: Pain Management, Opioid Use Disorder, and Buprenorphine Implementation: Updates on Prescribing

Here's an explanation of the effectiveness of non-opioid therapies compared to opioids for acute and chronic pain management:

Acute Pain Management:

• Non-Opioid Therapies:

  • Often as effective as opioids: For many common types of acute pain, non-opioid therapies, including both pharmacologic (e.g., NSAIDs, acetaminophen) and non-pharmacologic (e.g., ice, heat, rest, exercise), are at least as effective as opioids.
  • First-line treatment: Multimodal analgesia (combining different non-opioid approaches) is often recommended as the first-line drug therapy for acute pain.
  • Fewer risks: Non-opioid therapies generally carry significantly lower risks of addiction, overdose, and serious adverse events compared to opioids.
  • Specific effectiveness: For acute musculoskeletal pain, opioids may not be more effective than non-opioid analgesics.
  • Emerging options: Newer non-opioid medications are being developed that target specific pain pathways with potentially fewer side effects.

• Opioid Therapies:

  • Effective for severe pain: Opioids can provide effective relief for severe acute pain or pain that doesn't respond to other treatment options.
  • Rapid onset (parenteral): Intravenous, intramuscular, or subcutaneous opioids have a faster onset of action than oral opioids.
  • Risk of harm: Even for acute pain, there is a potential for patients to experience harm related to new opioid prescriptions, including the risk of long-term opioid use.
  • Not always superior: For some types of acute pain, such as low back pain and pain after third molar extractions, the efficacy of opioids is less clear, and their superiority to other medications is not established.
  • Adverse events: Opioids are associated with a wide range of adverse effects, including slowed breathing, gastrointestinal issues, somnolence, dizziness, and pruritus.

Chronic Pain Management:

• Non-Opioid Therapies:

  • Preferred approach: Non-opioid therapies (both pharmacologic and non-pharmacologic) are generally preferred for subacute and chronic pain.
  • Wide range of options: These include:
    • Pharmacologic: NSAIDs, acetaminophen, selected anticonvulsants (e.g., gabapentin, pregabalin), selected antidepressants (e.g., tricyclic antidepressants, SNRIs), topical agents (e.g., capsaicin, lidocaine patches).
    • Non-pharmacologic: Physical therapy, exercise, cognitive behavioral therapy (CBT), acupuncture, mindfulness, stress reduction, manual therapies, injections/nerve blocks, transcutaneous electrical nerve stimulation (TENS).
  • Improvements in pain and function: Many non-opioid approaches can improve pain and function for chronic conditions like low back pain, fibromyalgia, and osteoarthritis.
  • Limited long-term evidence for some: While short-term benefits are seen with specific non-opioid pharmacologic agents for certain conditions, long-term evidence for sustained efficacy can be limited for some options.
  • Reduced risks: They carry a much lower risk of addiction and overdose compared to opioids.

• Opioid Therapies:

  • Small, short-term benefits: Opioids may provide small improvements in pain and function in the short-term (1 to <6 months) compared to placebo.
  • Limited long-term evidence: Evidence on the intermediate-term and long-term benefits of opioids for chronic pain is very limited.
  • Increased risks: Opioids are associated with an increased risk of serious harms, including:
    • Opioid use disorder (addiction).
    • Overdose.
    • All-cause mortality.
    • Falls and fractures.
    • Myocardial infarction.
  • Not superior to non-opioids: In short-term follow-up, evidence shows no significant difference between opioids and non-opioid medications in improving pain, function, or other outcomes for chronic pain.
  • High discontinuation rates: Patients often discontinue opioid therapy in clinical trials due to adverse events.
  • Functional concerns: Some studies suggest that long-term opioid use may hinder return to work and potentially worsen physical functioning.

Source: Google Gemini

A Systematic Review and Meta-analysis of Opioids vs Nonopioids in Acute Pancreatitis
https://www.sciencedirect.com/science/article/pii/S277257232100011X

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain
https://pmc.ncbi.nlm.nih.gov/articles/PMC5885909/

FDA Approves Novel Non-Opioid Treatment for Moderate to Severe Acute Pain
https://www.fda.gov/news-events/press-announcements/fda-approves-novel-non-opioid-treatment-moderate-severe-acute-pain

Nonopioid Therapies for Pain Management
https://www.cdc.gov/overdose-prevention/hcp/clinical-care/nonopioid-therapies-for-pain-management.html

Non-Opioid and Non-Pharmacologic Treatment Modalities
https://mn.gov/dhs/opip/opioid-guidelines/factors-in-treatment/non-opioid-non-pharmacologic-treatement.jsp

Opioid Treatments for Chronic Pain
https://effectivehealthcare.ahrq.gov/products/opioids-chronic-pain/research

Here are some best practices in screening, diagnosing, and treating opioid use disorder (OUD):

Screening for Opioid Use Disorder (OUD):

• Universal Screening: Implement routine, universal screening for OUD in all clinical settings, including primary care, emergency departments, and inpatient units. This helps identify individuals early who may benefit from intervention.
• Validated Tools: Utilize validated screening tools. Examples include:
  • TAPS (Tobacco, Alcohol, Prescription medications, and other Substance) Tool: Assesses for tobacco, alcohol, prescription drug, and illicit substance use.
  • DAST-10 (Drug Abuse Screen Test): A self-administered or clinician-administered survey for drug abuse.
  • OUDIT (Opioid Use Disorder Identification Tool): A specific tool for opioid use.
  • SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised) and ORT (Opioid Risk Tool): Useful for patients being prescribed opioids for chronic pain.
• Integrate into Workflow: Embed screening seamlessly into existing clinical workflows (e.g., during vital signs, annual wellness visits, or intake forms).
• Non-judgmental Approach: Foster a non-judgmental and supportive environment to encourage honest disclosure from patients. Address potential stigma associated with OUD.
• Consider Polysubstance Use: Screen for the use of other substances and co-occurring mental health disorders, as these often complicate OUD.

Diagnosing Opioid Use Disorder (OUD):

• DSM-5-TR Criteria: The diagnosis of OUD is based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR) criteria. A problematic pattern of opioid use leading to clinically significant impairment or distress, manifested by at least 2 out of 11 criteria within a 12-month period. These criteria include:
  • Using larger amounts or for a longer period than intended.
  • Persistent desire or unsuccessful efforts to cut down or control opioid use.
  • Spending a great deal of time obtaining, using, or recovering from opioids.
  • Craving or a strong desire or urge to use opioids.
  • Problems fulfilling obligations at work, school, or home.
  • Continued use despite recurring social or interpersonal problems.
  • Giving up or reducing important activities because of opioid use.
  • Using opioids in physically hazardous situations.
  • Continued use despite ongoing physical or psychological problems likely caused or worsened by opioids.
  • Tolerance (need for increased amounts or diminished effect with continued use).
  • Withdrawal (opioid withdrawal syndrome or taking opioids to avoid withdrawal).
• Comprehensive Assessment: Conduct a thorough history and physical examination, including:
  • Detailed substance use history (onset, duration, patterns, routes of administration).
  • Assessment of past treatment attempts and responses.
  • Medical and psychiatric comorbidities.
  • Social and functional assessment (home, work, relationships).
  • Physical signs of opioid use or withdrawal (e.g., needle marks, pupillary changes).
• Urine Drug Screening: Utilize urine drug screens to confirm opioid use, monitor adherence to treatment, and detect other substance use.
• Severity Assessment: Determine the severity of OUD (mild, moderate, severe) based on the number of DSM-5-TR criteria met, as this can inform treatment decisions.

Treating Opioid Use Disorder (OUD):

• Medication for Opioid Use Disorder (MOUD): This is the gold standard and most effective treatment for OUD.
  • Methadone: A long-acting opioid agonist, available only through SAMHSA-certified opioid treatment programs (OTPs). Reduces cravings and withdrawal, and blocks the effects of other opioids.
  • Buprenorphine (often combined with naloxone): A partial opioid agonist, available in various formulations (sublingual tablets/films, extended-release injections, implants). Can be prescribed by waivered clinicians in office-based settings. Suppresses cravings and withdrawal and blunts effects of other opioids.
  • Naltrexone (oral or extended-release injectable): An opioid receptor antagonist. Blocks the euphoric and sedative effects of opioids. Requires a period of opioid abstinence before initiation to avoid precipitated withdrawal. Can be prescribed by any licensed clinician.
  • Emphasize Long-Term Treatment: MOUD should be continued for as long as it helps the patient, as discontinuation increases the risk of relapse and overdose.
• Psychosocial Interventions: While MOUD is primary, behavioral therapies can be a valuable adjunct.
  • Cognitive Behavioral Therapy (CBT): Helps patients identify and change problematic thoughts and behaviors related to opioid use.
  • Contingency Management: Provides incentives for desired behaviors (e.g., negative drug tests).
  • Motivational Interviewing: Helps patients explore and resolve ambivalence about treatment and behavior change.
  • Individual and Group Counseling: Provides support, education, and skill-building.
  • Recovery Support Services: Include peer support groups (e.g., Narcotics Anonymous) and peer recovery coaches.
• Comprehensive Care:
  • Integrated Care: Treat OUD as a chronic medical condition, integrating care into primary care settings whenever possible.
  • Address Comorbidities: Screen for and treat co-occurring medical and mental health conditions (e.g., depression, anxiety, hepatitis C, HIV).
  • Harm Reduction: Provide education on overdose prevention and distribute naloxone to patients with OUD and their significant others.
  • Patient-Centered Approach: Develop individualized treatment plans based on patient preferences, needs, and goals.
  • Continuity of Care: Ensure seamless transitions between different levels of care (e.g., inpatient to outpatient, criminal justice settings to community care).
  • Telehealth: Utilize telehealth for MOUD appointments, as it can improve access and retention in treatment, especially for patients facing transportation or stigma barriers.

Source: Google Gemini

CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022
https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm

Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families: Updated 2021 [Internet]
https://www.ncbi.nlm.nih.gov/books/NBK574912/

Opioid Use Disorder, StatPearls [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK553166/

Opioid Use Disorder Diagnosis and Treatment Guideline, Kaiser Permanente
https://wa-provider.kaiserpermanente.org/static/pdf/public/guidelines/opioid-use-disorder.pdf

Screening for Opioid Use Disorder (OUD), Michigan Safer Opioid Prescribing Tool Kit
https://injurycenter.umich.edu/opioid-overdose/michigan-safer-opioid-prescribing-toolkit/post-overdose-toolkit/screening-for-oud/#:~:text=Screening%20for%20Opioid%20Use%20Disorder%20(OUD)

Here are some strategies to minimize opioid use in clinical practice:

Prioritizing Non-Opioid Approaches:

• First-Line Non-Opioid Therapies: Emphasize non-pharmacologic and non-opioid pharmacologic treatments as the first-line approach for most pain conditions, both acute and chronic. This includes:
  • Non-pharmacologic: Physical therapy, exercise, acupuncture, massage, heat/cold therapy, cognitive behavioral therapy (CBT), mindfulness, relaxation techniques.
  • Non-opioid pharmacologic: NSAIDs, acetaminophen, topical analgesics, select antidepressants (e.g., SNRIs, tricyclics for neuropathic pain), select anticonvulsants (e.g., gabapentin, pregabalin for neuropathic pain).
• Multimodal Analgesia: Implement a multimodal approach that combines different types of pain relievers and non-pharmacologic strategies. This can provide better pain control with lower doses of individual medications, including opioids if used.
• Realistic Pain Expectations: Educate patients that the goal of pain management is often not complete pain eradication, but rather functional improvement and a reduction in pain to a manageable level. This helps manage patient expectations and reduces the pressure for higher opioid doses.

Responsible Opioid Prescribing Practices (When Opioids Are Necessary):

• Thorough Patient Assessment:
  • Comprehensive Pain Evaluation: Conduct a thorough assessment of the patient's pain, including its cause, severity, impact on function, and previous treatments.
  • Risk Stratification: Assess the patient's risk for opioid misuse, abuse, and OUD using validated screening tools. Consider factors like personal or family history of substance use disorder, mental health conditions, and concomitant use of other sedating medications (e.g., benzodiazepines).
  • Right Indication: Ensure opioids are prescribed only for appropriate indications where their benefits outweigh the risks. Avoid opioids for chronic or undifferentiated pain where other treatments have not been thoroughly explored.
• Start Low, Go Slow, and for Short Duration:
  • Lowest Effective Dose: Prescribe the lowest effective dose for the shortest necessary duration.
  • Acute Pain Limits: For acute pain, limit the duration of opioid prescriptions to the expected period of severe pain, often 3-7 days.
  • Avoid Long-Acting/ER Opioids for Initial Prescriptions: Avoid prescribing long-acting or extended-release opioids for acute pain or as initial opioid therapy.
• Prescription Drug Monitoring Programs (PDMPs):
  • Mandatory Checks: Routinely check the state PDMP database for all patients receiving opioid prescriptions. This helps identify "doctor shopping" and concurrent prescriptions from multiple providers, which can indicate misuse or diversion.
  • Monitor Co-prescribing: Pay close attention to co-prescribing of opioids with benzodiazepines or other central nervous system depressants, as this significantly increases overdose risk.
• Patient Education and Shared Decision-Making:
  • Informed Consent: Discuss the risks and benefits of opioid therapy, including potential side effects, risks of addiction, overdose, and safe storage and disposal.
  • Treatment Agreements: Consider using opioid treatment agreements, which outline patient and prescriber responsibilities, goals of therapy, and conditions for continued opioid use.
  • Naloxone Co-Prescribing: Offer or co-prescribe naloxone to all patients receiving opioid prescriptions, especially those at higher risk of overdose (e.g., higher doses, concurrent benzodiazepine use, history of substance use disorder).
• Regular Reassessment and Monitoring:
  • Functional Goals: Focus on functional improvement and quality of life, not just pain scores, as measures of treatment success.
  • Periodic Reassessment: Regularly reassess the need for continued opioid therapy, especially for chronic pain. If goals are not met or risks outweigh benefits, consider tapering or discontinuing opioids.
  • Urine Drug Testing (UDT): Consider periodic UDT to monitor for adherence to prescribed medications and detect unprescribed or illicit substance use.
• Safe Disposal: Educate patients on proper disposal of unused opioids to prevent diversion and accidental exposure. Provide information on drug take-back programs or in-home disposal methods.

System-Level Strategies and Collaboration:

• Clinical Practice Guidelines: Adhere to evidence-based guidelines for opioid prescribing (e.g., CDC Clinical Practice Guideline for Prescribing Opioids for Pain).
• Opioid Stewardship Programs: Implement opioid stewardship programs within healthcare systems to standardize prescribing practices, provide clinician education, and monitor opioid use patterns.
• Interdisciplinary Collaboration: Work collaboratively with pain specialists, addiction medicine specialists, mental health professionals, pharmacists, physical therapists, and other healthcare providers to offer comprehensive pain management.
• Access to MOUD: Ensure easy access to Medication for Opioid Use Disorder (MOUD) for patients who develop OUD.
• Continuing Education: Provide ongoing education for clinicians on best practices in pain management, including non-opioid strategies, safe opioid prescribing, and OUD recognition and treatment.

Source: Google Gemini

Community-Based Cluster-Randomized Trial to Reduce Opioid Overdose Deaths
https://www.nejm.org/doi/full/10.1056/NEJMoa2401177

Emergency department strategies to combat the opioid crisis in children and adolescents
https://www.sciencedirect.com/science/article/pii/S2688115224009329

Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder: Strategies to Address Key Barriers Within the Treatment System
https://nam.edu/perspectives/improving-access-to-evidence-based-medical-treatment-for-opioid-use-disorder-strategies-to-address-key-barriers-within-the-treatment-system/

Primary Care–Relevant Interventions to Prevent Opioid Use Disorder: Current Research and Evidence Gaps 
https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/prevention-of-opioid-user-disorder-ehc-tech-brief.pdf

Responsible Controlled Substance and Opioid Prescribing, StatPearls [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK572085/

Strategies to Deimplement Opioid Prescribing in Primary Care A Cluster Randomized Clinical Trial
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2824679