If problematic drug-related behavior is identified during
long-term opioid therapy, the clinician must decide among several actions:
- revise the structure for prescribing and continue opioid treatment,
- continue treating pain without opioids, or
- discharge the patient from the practice.
In the United States, opioid therapy cannot be continued if the clinician
believes that the patient has engaged in diversion of a controlled prescription
drug to the illicit market. This is uncommon. More often, the decision must
be made in response to the occurrence of problematic behaviors that could
reflect any of a number of diagnostic possibilities (see
Establishing a Diagnosis for Problematic Drug-Related Behavior). To pursue the most appropriate
course, the clinician should establish a working diagnosis and make a judgment
about the potential for a future characterized by a favorable balance between
the positive outcomes associated with opioid therapy (pain relief and functional
gains) and the ongoing risks.
If the decision is made to continue prescribing opioids, a new structure
for prescribing should be initiated that is appropriate to the severity
of the behaviors demonstrated by the patient. If the problem behavior is
relatively minor, e.g., unsanctioned dose escalation once or twice, the
change in structure may incorporate relatively little, perhaps more frequent
visits and smaller quantities prescribed. If, however, the assessment indicates
that the behaviors were serious and the risk of future problems is moderate
to high, any of a range of strategies may be implemented. These strategies,
which are very similar to those that should be considered proactively at
the start of therapy, are designed to increase monitoring and assist the
patient in maintaining control over the therapy (see table).
Table: Reactive Strategies That May Be Used to Reduce The Likelihood
of Problematic Drug-Related Behaviors and Increase Monitoring (.pdf)
Patients should be taught that the new structure for prescribing is not
punitive, but therapeutic. It may be useful to explain that these controls
are necessary to allow the clinician to act in the patient's best interest.
If therapy must be restructured, documentation must be comprehensive and
complete. The medical record should reflect the thoughtful reassessment
and the written plan should be explicit.
The clinician must also decide about the need for referral. If a diagnosis
of addiction is tenable, this should be recognized as a serious disease
and referral to a specialist in addiction medicine or an addiction program
should be strongly considered. Referral to a pain specialist or to a mental
health care provider (other than an addiction specialist) should also be
considered, where appropriate.
References:
Portenoy RK, Payne R, Passik S: Acute and chronic pain. In
Lowinson JH, Ruiz P, Millman RB (eds): Comprehensive Textbook of
Substance Abuse, Fourth Edition. Baltimore: Williams and Wilkins,
in press. |