Responsible opioid prescribing

Dr Helen Fulcher, Goodfellow GP Advisor talks with Northland General Practitioner and Addiction Medicine Specialist Dr Alistair Dunn about opioids in the context of pain management in the non-palliative setting.

Topics covered include:

  • Reframing pain management from curative to functional for chronic pain.
  • Prescribing opiates - limited indications for prescribing, checking for red flags and tips for safe prescribing.
  • Opioid substitution treatment – goals of treatment, available medication, increasing awareness of co morbid conditions in primary care.

  

   

Resources

  

Peer group discussion points

Patients with prominent pain issues are often in significant distress and may have an expectation that pain may be ‘cured’ or ‘fixed’ by their treating physician.

  • How do you approach patient expectations regarding pain? Are you able to have a discussion with your patient about changing the way they think about pain? How do you manage issues of patient frustration and anger?

  • Alastair discusses framing treatment as managing pain rather curative pain outcomes, e.g. outlining functional goals rather than focusing on the pain. Do you have any tips that you are able to share with your peer group as an approach that has worked for you in the past?

Opioid prescribing may be required for acute pain and short-term prescribing.  Alastair discusses his methods for prescribing when required.  These may include tight dispensing arrangements e.g. weekly, clarifying a maximum dose, efficacy, on going indication and being ready to stop the medication if no benefit is found.  

  • What are your current prescribing habits and how do you safe guard against inappropriate prescribing?

  • Do you routinely discuss the risks of the medication (e.g. overdose, respiratory depression, alcohol interaction, addiction) and other potentials hazards such as safe storage to reduce risk of diversion?

Assessment of new patients potentially requiring opioid treatment, or reviewing current patients using opioids in part involves identifying risk, red flags and review of ongoing indication.

  • Alastair mentions that any prior addiction is a risk factor for opioid dependence. Do you routinely assess for past history or addiction? If so, how do you do this?

  • Universal precaution is a suggested approach to prescribing – at what point can you identify where tools such as initiating contracts around dispensing and dosing limits may come in to effect?  Does a urine drug screen have a role in your practice for such patients? 

  • Are you able to identify the cognitive, behavioural and psychological features of opioid dependency? And are you familiar with the local pathways for CAD advice and input if needed?

  • Have you taken the opportunity to audit your patients on long term opioids to determine if opioid prescribing is still indicated?

Opioid Substitution Treatment (OST) provides a regular daily dose of opioids to keep an individual stable and avoid withdrawals.  The goal is stability and reducing relapse into illegal drug use. 

  • For your patients that are in an OST programme, medications such as methadone or saboxone are used.  Are you aware of how the medications work and the potential sides effects that may impact on patient management or prescribing?

  • Patients that have a substance use disorder often have complex co-morbidities and are at higher risk of mortality for health problems such as heart and liver disease. How do you ensure that you closely manage these patients?
Date Published: 
Wednesday, October 23, 2019