SCENARIO 1: Starting opioids, discussing monitoring
Name: Mr. Robert Jones
Marital status: Married with two children
Occupation: Hardware store manger
Pain issue: Chronic right ankle and foot pain
This is the second visit to this doctor. He transferred his primary care to this doctor because his previous doctor moved out of state. He had been seeing his previous doctor for over 10 years and had an excellent relationship with him. He is worried about having a new doctor. He presented last month (his first visit) with a copy of his old medical records which includes notes from his previous doctor and his orthopedic surgeon.
“ He has taken multiple medications over the past year for his pain including naproxen, acetaminophen, and tramadol. All of these medications were unhelpful.
Two years ago, he fractured his right ankle and foot when he fell off a ladder while cleaning out the gutters. He had been drinking beer with friends earlier in the day while watching baseball, but he has not connected his accident to his alcohol use. His ankle/foot fracture required several surgeries with placement of screws and plates to restore function. His orthopedist recently told him that his ankle and foot are "well-healed" but will likely always cause him significant pain and will never be “normal”. He was told that no additional surgeries are needed at this time.
His orthopedist also told him that his primary care doctor should take over the treatment of his ankle and foot pain. He has taken multiple medications over the past year for his pain including naproxen, acetaminophen, and tramadol. All of these medications were unhelpful.
The prescription monitoring program data shows NO history of previously prescribed controlled substances.
On physical examination his right ankle and foot are somewhat deformed from the facture and surgeries, and he has very tender areas on the top and inside of his right foot. His left hip exam is completely normal.
The interview starts with the doctor having a conversation about how the patient’s pain is on the ibuprofen (Motrin) plus acetaminophen (Tylenol) taken 3 times per day that were prescribed at the last visit (1 month ago).
Assess patient’s pain, function and baseline risk for opioid analgesic misuse
Prior to prescribing opioids:
- Assess baseline pain, function and quality of life
Assess for baseline risk of opioid misuse
- Young age
- Personal history of substance abuse including illicit and prescription drugs, alcohol, and nicotine
- Family history of substance abuse
- Legal history (DUI, incarceration)
- Mental health problems
- Determine if potential benefits of opioid analgesics outweighs potential risks (opioid misuse)
Discuss the potential risks and benefits of opioid analgesics for patient's chronic pain
- Physical dependence
- Toxicity/side effects (e.g., Sedation, constipation, urinary retention)
- Quality of life
Discuss treatment plan including the monitoring strategies that will be required
- Discuss realistic goals and expectations of opioid therapy
- Discuss importance of focusing on functional improvements
- Assess benefit periodically using scales to assess pain, function, quality of life
Use "Universal Precautions" to monitor and document any harm (e.g., aberrant medication taking behavior). Use consistent approach, but set level of monitoring to match risk.
- Agreements/informed consent
- Drug testing
- Pill counts (zero tolerance for escalation of dose in between visits)
- Prescribe small quantities initially
- Frequent visits initially
- Establish a refill and cross coverage system
- Review Prescription Monitoring Program data for "questionable activity"
- Discuss agreements, pill counts, drug tests, etc. as ways that you are helping to protect patient from getting harmed by opioid medications.