In This Edition
9 Things: At a Glance
An occasional series providing specialty-specific advice for hospitalists from experts in the field.
- Recognize the differential diagnosis for pain exacerbation in a chronic opioid therapy (COT) patient/chronic pain patient.
- Know where the opioids are going.
- Sometimes stopping pills, rather than adding them, can cure pain.
- Take time to educate patients about methadone and its risk of mortality if not used as prescribed.
- A little local anesthetic (and some steroid) goes a long way.
- Addiction to opioids is not rare.
- Safely changing opioid regimens requires good math and good judgment.
- For a low-risk chronic pain patient on low-dose opioids, don’t change the regimen, even if the indication for opioids isn’t clear.
- If a patient has pain all the time, they need to be on a medication that works all the time.
The differential diagnosis for pain exacerbation in a chronic opioid therapy (COT) patient/chronic pain patient is:
- Worsening medical problem;
- New medical problem;
- Nonopioid problem (side effect);
- Opioid problem (resistance/tolerance/side effect); and
- Opioid-induced hyperalgesia.
The search for an etiology and treatment for chronic pain should not end, even if a patient is labeled with “chronic pain syndrome.” The patient could simply be chronically undiagnosed or on an incorrect therapy.
Know where the opioids are going.
Whether it’s auditing a prescription-monitoring program (PMP), checking a urine drug screen, or calling a pharmacist, try to ensure that chronic pain patients are taking the opioids as prescribed. A phone call to the primary opioid prescriber or chronic pain provider could save a busy hospitalist a lot of time.
Using PMP data can consume a lot of time. Typically, only prescribing providers can access PMPs, so delegating this responsibility to someone else is not possible. If your state PMP does not help, simply call the patient’s pharmacy and ask for the last three fill dates on an opioid prescription. This also works well in case the patient’s pharmacy doesn’t participate in a PMP or is delayed in uploading recent prescriber data. Many COT patients have an opioid treatment agreement with their prescriber and must use only one pharmacy to fill opioids.
In January 2013, the University of North Carolina Injury Prevention Center published an analysis of three years of North Carolina PMP data.1 Patients followed by providers who consistently used the state PMP were five times more likely to receive treatment for opioid dependence compared with patients of providers who never used the state PMP.1
Why go through all this trouble if a chronic pain specialist is also doing it? It’s good documentation and good care, like monitoring levels of transplant meds or making sure hemoglobin A1Cs are up to date and trending toward goal. It may only take one misused or diverted opioid pill to result in a serious adverse event.
Sometimes stopping pills, rather than adding them, can cure pain.
Many chronic pain patients accumulate a patchwork of pills (e.g. benzodiazepines, opioids, muscle relaxants, and antidepressants). Many interpret noxious symptoms associated with the drug burden as “uncontrolled pain.” Two conditions that might afflict the pain sufferer who takes multiple medications are opioid-induced hyperalgesia (OIH) and medication-overuse headaches (MOH). They are uncommon but should be on a hospitalist’s differential for difficult-to-control chronic pain. Opioids commonly are implicated in causing MOH, a chronic headache occurring at least 15 days a month, four hours a day if untreated, and for at least three consecutive months. OIH is a nociceptive sensitization caused by opioids that can occur suddenly or insidiously.
If a drug isn’t absolutely necessary, stop it. If you and the patient start by agreeing to the shared goal of improving health, the conversation should go better. An axiom we learned from mentors at the University of Washington is: “There is no pain that cannot be made worse with inappropriate therapy.”