Using Your State Prescription Drug Monitoring Program (PDMP) Effectively
When initiating opioid therapy for a patient, it’s crucial to approach the treatment process systematically and collaboratively. Opioid medications, while effective in managing certain types of pain, carry risks such as dependence, overdose, and side effects. A structured and transparent approach can help mitigate these risks and set realistic expectations for both the healthcare provider and the patient.
1. Come to Agreement on the Problem
Before starting opioid therapy, it is essential to first establish a clear understanding of the problem being treated. This includes not only identifying the type of pain but also ensuring that both the patient and provider are aligned on the treatment goals.
- Clarify the Pain Issue: Work with the patient to identify the specific pain condition, e.g., XYZ Pain. Ensure that both parties agree on the diagnosis and the nature of the pain being treated.
- Define Treatment Goals: The treatment goals should be specific and measurable. These goals must reflect the patient’s needs and be expressed in the patient’s own words. Ideally, these goals should be attainable through opioid therapy, but they could also involve other therapies to be more comprehensive.
Examples of Patient Treatment Goals:- “Using this medication will help me get out of the house with my wife twice per week.”
- “It will allow me to watch my grandchildren every weekend.”
- “It will enable me to plant and maintain a vegetable garden this summer.”
- “It will allow me to return to work full time.”
- “It will help me decrease days off from work (compared to last year when I took 23 sick days).”
- “It will help me get comfortable enough to lie down in bed.”
It’s important that these goals are not just agreed upon verbally, but also endorsed by the patient, ensuring they understand and take ownership of what the treatment aims to achieve.
2. Present Opioids as a Trial
Opioid therapy should be presented as a trial, not as a long-term, guaranteed solution. Patients should understand that the goal is symptom relief and functional improvement, not just the reduction of pain intensity. If the prescribed opioids do not help the patient meet their defined goals, the therapy should be discontinued, and alternative treatments should be explored.
- Trial Approach: “If this medication does not help you achieve these goals, we will stop the opioid therapy and explore other treatment options.”
- Reassess Goals: Even if pain reduction is achieved, be open to revisiting and adjusting treatment goals if initial objectives are not fully met.
3. Have the Patient Sign Informed Consent
Before prescribing opioids, ensure that the patient signs an informed consent form that outlines the risks and benefits of opioid therapy. This should be done as part of a controlled substance agreement to ensure both parties understand the parameters of the treatment.
- Discuss Risks and Benefits: Thoroughly review the risks and benefits of opioid therapy, focusing on both the potential advantages and serious risks. Ensure the patient is fully aware of what is involved in the treatment.
Potential Benefits of Opioid Therapy
- Analgesia: Some patients experience significant pain relief, which can improve overall quality of life and functionality.
- Improved Functional Status: In certain cases, opioid therapy may enhance the patient’s ability to perform daily activities and reduce disability. However, note that much of the evidence comes from pharmaceutical-sponsored trials, which may have limitations regarding:
- Short trial duration.
- Limited study populations (excluding those with co-morbidities or addiction issues).
Potential Risks of Opioid Therapy
The risks of opioid therapy need to be communicated clearly. These risks vary depending on the patient’s medical history, concurrent medications, and individual response to opioids.
- Adverse Effects:
- Sedation and Respiratory Depression: Opioids are well known for causing sedation, which can lead to respiratory depression, especially at higher doses. Patients should be aware of these risks, particularly if they have pre-existing sleep apnea or other respiratory conditions.
- Constipation: Unlike other side effects, constipation does not diminish over time with opioid use. It’s crucial to address this from the outset and consider laxatives or other interventions.
- Tolerance: Tolerance to opioids means that over time, the patient may need higher doses to achieve the same effect, which increases the risk of side effects.
- Physical Dependence: Physical dependence can develop with long-term opioid use. Withdrawal symptoms may occur if the medication is suddenly stopped or tapered too quickly.
- Opioid-Induced Hyperalgesia: Some patients experience increased pain as a result of long-term opioid therapy, a phenomenon known as opioid-induced hyperalgesia. This may occur without a clear mechanism and is important to monitor.
- Allergies and Organ Toxicity: Although rare, opioids can cause allergic reactions or damage to organs such as the liver and kidneys.
- Addiction and Overdose: Though addiction is not common among patients receiving opioids for legitimate pain, it is a potential risk, especially in individuals with a history of substance abuse or co-occurring mental health issues. Overdose remains one of the leading causes of death among individuals who misuse opioids.
- Collateral Risks: There is a risk of ingestion and overdose by children, particularly in households where young children are present. Proper storage and safety protocols should be discussed to minimize this risk.
4. Review Monitoring Practices
Once opioid therapy is initiated, monitoring is key to ensuring the treatment remains effective and safe.
- Urine Drug Screens: Regular monitoring through urine drug screens (UDS) helps ensure the patient is adhering to the prescribed treatment plan and not misusing other substances.
- Prescription Refill Policy: Establish a clear policy for refills and monitor prescription requests carefully to ensure they are in line with the treatment goals.
- Set Up Regular Follow-Up Visits: Arrange for follow-up visits every 4-6 weeks to assess the effect of the pain medication. This is an opportunity to evaluate progress, discuss any issues or concerns, and make adjustments to the treatment plan if necessary.
5. Plan for Stopping Opioid Therapy
As part of the treatment plan, it is essential to have a strategy for discontinuing opioids if the risks outweigh the benefits or if the treatment goals are not being met.
- Discontinuation Strategy: Discuss potential scenarios in which opioid therapy may need to be discontinued, such as the development of tolerance, adverse effects, or lack of efficacy.
- Gradual Tapering: If opioid therapy needs to be stopped, ensure the process is gradual to minimize withdrawal symptoms and complications.
Additional Resources
- How to Discuss Stopping Opioid Therapy with the Patient: Guidance on how to approach the sensitive topic of tapering or discontinuing opioids.
CDC Guidelines for Prescribing Opioids for Chronic Pain: Comprehensive guidelines on opioid prescribing that emphasize a balanced, patient-centered approach to pain management.