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For core clinical content designed to help you safely and effectively manage patients with chronic pain, when appropriate, with opioid analgesics, please visit our sister site, SCOPE of Pain.

 

  1. Optimizing Office Systems
  2. Office Systems Safe and Competent Opioid Prescribing: Optimizing Office Systems Program CME Post-Test Evaluation
  1. Massachusetts Laws
  2. Educational Program Making Sense of Massachusetts Opioid Prescribing Laws and State and National Guidelines Program CME Post-Test Evaluation
  1. Dental Pain
  2. Educational Program Safe Opioid Prescribing for
    Acute Dental Pain
    Program CME Post-Test Evaluation
  1. Prescribe to Prevent
  2. Educational Program Prescribe to Prevent: Overdose Prevention and Naloxone Rescue Kits for Prescribers and Pharmacists Information Program CME Post-Test Evaluation
  1. Military Modules
  2. Module 1 Military SCOPE of Pain: Safe and Competent Opioid Prescribing For Providers Working with Veterans and Military Service Personnel Information Video CME Post-Test Evaluation
  3. Module 2 Military SCOPE of Pain: Safe and Competent Opioid Prescribing For Providers Working with Veterans and Military Service Personnel Information Video CME Post-Test Evaluation
  1. Video Modules
  2. Module 1 Case Studies In Practice: Applying Principles
    of Safe Opioid Prescribing
    Information Introduction Cases Case I Case II Case III Certification CME Post-Test Evaluation
  3. Module 2 Complex Convrs. High Dose Opioids
    & Illicit Drug Use
    Information Introduction Cases Case I-A Case I-B Case II Certification CME Post-Test Evaluation
  4. Module 3 Using the PDMP PMP Questionable Activity Information Introduction Cases Case I Case II Certification CME Post-Test Evaluation

SCENARIO 3: Addressing lack of opioid benefit and excessive risk, discontinuing opioids SCENARIO 3: Addressing lack of opioid benefit and excessive risk, discontinuing opioids

Name: Mrs. Lindsey Beecher
Age: 43
Marital status: Married, 1 son age 22 and 1 granddaughter age 2
Occupation: Elementary school teacher
Pain issue: Chronic painful diabetic neuropathy

This is an early follow-up visit scheduled after the patient was seen in an outside emergency room over the weekend for worsening foot pain. She has been followed by this primary care doctor for the past 6 months.

 

She describes her pain as “9-10” out of 10 all the time. She recently had her methadone dose increased from 15 mg to 20 mg three times per day.

The Scenario:

The patient’s pain is in both feet and is burning and sharp all the time and worse at night when the sheets touch her feet. She is considering going on disability due to her severe foot pain. She describes her pain as “9-10” out of 10 all the time. She recently had her methadone dose increased from 15 mg to 20 mg three times per day. She is also on Neurontin 600 mg three times per day. Previous to seeing this doctor she had been tried on sustained release morphine and then fentanyl patch without improvement in her pain.

She has an up-to-date controlled substances agreement that outlines the need for adherence with close monitoring, including urine drug tests, pill counts and taking her medications (e.g. methadone) exactly as prescribed and NOT increasing her dose without first discussing it with her doctor.

She went to an emergency room on Saturday night because she ran out of her methadone after doubling her dose because her pain was unbearable. Review of the State on-line prescription monitoring program data confirmed that she was prescribed 30 tablets of methadone 20 mg by the emergency room doctor.

The interview starts with a conversation about her recent emergency room visit and her aberrant medication-taking behaviors.

 

Clinician Tasks:
Discuss patient’s aberrant medication taking behaviors (unsanctioned dose escalation, lack of compliance with pill count)

  • State your concerns about the aberrant behavior using a non-judgmental approach
  • Use open-ended questions
  • Examine the patient for signs of flexibility - Is the patient focused more on obtaining more opioid or on pain relief?

 

Discuss the lack of apparent benefit (9-10 out of 10 pain) and increased risk (over-sedation) of methadone

  • Exit Strategies for a patient where risk/harm is greater than benefit
    • Stress how much you believe/empathize with the patient’s pain severity and impact
    • Express frustration regarding the lack of a good pill to “fix” the pain
    • Focus on the patient’s strengths and encourage therapies for “coping with” the pain (cognitive behavioral therapy, alternatives such as acupuncture, etc.)
    • Show commitment to continue caring about and for the patient but without opioids
      • Discuss non-opioid and non-pharmacotherapies
    • Stress that some patients experience improvement in function and pain control when chronic opioids are stopped.
    • Make it clear that you are not discharging the patient but discontinuing an ineffective and seemingly harmful treatment for this patient
    • If patient is physically dependent, taper patient slowly over 3-4 weeks to minimize opioid withdrawal
    • Schedule close follow-ups during and after taper
  • Exist Strategies for patient where there is concern for addiction
    • Focus on the patients behaviors that make you concerned for possible addiction
      • Loss of Control (e.g., running out early, obtaining scripts from other providers)
      • Compulsive use (e.g., overly focused on opioids rather than pain control)
      • Continued use despite harm (e.g., request more opioid despite dangerous side effects such as sedation)
    • Discuss these behaviors in a non-judgmental manner
    • If patient is physically dependent taper opioids slowly over 3-4 weeks to minimize opioid withdrawal
    • Offer patient referral to specialty addiction treatment
    • Make it clear that you are not discharging the patient but discontinuing a treatment that has become too risky for the patient
    • Schedule close follow-ups during and after taper

 

Discuss the need for tapering her methadone and treating her pain with nonopioids and nonpharmacotherapy

  • Exit Strategies for patient where there is concern for addiction
  • Focus on the patients behaviors that make you concerned for possible addiction
    • Loss of Control (e.g., running out early, obtaining scripts from other providers)
    • Compulsive use (e.g., overly focused on opioids rather than pain control)
    • Continued use despite harm (e.g., request more opioid despite dangerous side effects such as sedation)
  • Discuss these behaviors in a non-judgmental manner
  • If patient is physically dependent taper opioids slowly over 3-4 weeks to minimize opioid withdrawal
  • Offer patient referral to specialty addiction treatment
  • Make it clear that you are not discharging the patient but discontinuing a treatment that has become too risky for the patient
  • Schedule close follow-ups during and after taper