Take Patient's Word in Judging Chronic Pain

ORLANDO – Do not confuse addiction with physical dependence when prescribing opioids for your chronic pain patients, Dr. Jennifer P. Schneider advised at the annual clinical meeting of the American Academy of Pain Management.

Trust patients to tell the truth when they complain of pain and counsel them about the side effects of opioids.

Dr. Schneider, an internist whose Tucson, Ariz., practice focuses on addiction medicine and pain management, stressed that the patient's word is the gold standard when it comes to judging his or her own pain. However, she said, “Doctors are uncomfortable with this.”

The field of chronic pain management is full of misconceptions, she added. For example, cancer pain is more likely to get treated than noncancer pain, because practitioners falsely believe patients will become addicted to their pain medications; some physicians may not be concerned about the risk for addiction in this population because they perceive these patients as being close to death.

“This is such faulty thinking. Addiction is not the same as physical dependence or tolerance. We've got to get that message across to clinicians,” she said.

Sometimes physicians get suspicious when patients complain that their original dose either relieves pain less effectively than before or has stopped altogether, Dr. Schneider said. “When this happens, ask patients about their function. Maybe they are having more pain because they are no longer just sitting on the sofa, like they used to. If they are now able to get up and walk the dog or do gardening, they will need more medication. So don't just assume it's tolerance, or worse, that they are drug seeking. If you don't want them to get back to lying on the sofa, prescribe more.”

Long-acting opioids are preferable over shorter-acting agents, because they produce even blood levels and more stable pain relief. Short-acting drugs are more likely to cause a “buzz” as they get taken up by the brain. Patients also have to get up in the middle of the night to take short-acting opioids to keep their blood levels constant.

Short-acting drugs are useful for acute pain, however, and can also be used for rescue dosing, Dr. Schneider said.

There is no evidence for major organ toxicity with opioids. However, constipation is a problem for virtually all patients, and they should be aware of the importance of adequate hydration to minimize this. A stool softener also may be of benefit, she said.

Opioids lower testosterone levels in men, which can put them at risk for osteoporosis. Dr. Schneider advised replacing the testosterone to prevent the loss of bone and to give men more energy and muscle strength.

The “big bugaboo” of opioid prescribing is diversion. “Are patients selling their drugs on the street? We all worry about this,” she said. To help guard against diversion, Dr. Schneider recommended doing routine drug screening with an additional screen for any special drugs that patients may be taking.

“A regular urine drug screen will pick up codeine, morphine, and heroin only, but not methadone, fentanyl, oxycodone, or hydrocodone. So when you use a urine drug screen, make sure you test for other drugs, if you suspect the patient is taking other substances.”

A drug screen is also good to make sure patients are using the drugs as prescribed, she added.

Dr. Schneider reported that she also has her patients sign a contract with her, in which they attest they will not engage in illegal or diversional activity and will take their medication in a responsible manner.

“If you do all these things and are victimized by someone who is a drug seeker, at least you have documented your efforts and have done everything you can do,” she said.

ORLANDO – Do not confuse addiction with physical dependence when prescribing opioids for your chronic pain patients, Dr. Jennifer P. Schneider advised at the annual clinical meeting of the American Academy of Pain Management.

Trust patients to tell the truth when they complain of pain and counsel them about the side effects of opioids.

Dr. Schneider, an internist whose Tucson, Ariz., practice focuses on addiction medicine and pain management, stressed that the patient's word is the gold standard when it comes to judging his or her own pain. However, she said, “Doctors are uncomfortable with this.”

The field of chronic pain management is full of misconceptions, she added. For example, cancer pain is more likely to get treated than noncancer pain, because practitioners falsely believe patients will become addicted to their pain medications; some physicians may not be concerned about the risk for addiction in this population because they perceive these patients as being close to death.

“This is such faulty thinking. Addiction is not the same as physical dependence or tolerance. We've got to get that message across to clinicians,” she said.

Sometimes physicians get suspicious when patients complain that their original dose either relieves pain less effectively than before or has stopped altogether, Dr. Schneider said. “When this happens, ask patients about their function. Maybe they are having more pain because they are no longer just sitting on the sofa, like they used to. If they are now able to get up and walk the dog or do gardening, they will need more medication. So don't just assume it's tolerance, or worse, that they are drug seeking. If you don't want them to get back to lying on the sofa, prescribe more.”

Long-acting opioids are preferable over shorter-acting agents, because they produce even blood levels and more stable pain relief. Short-acting drugs are more likely to cause a “buzz” as they get taken up by the brain. Patients also have to get up in the middle of the night to take short-acting opioids to keep their blood levels constant.

Short-acting drugs are useful for acute pain, however, and can also be used for rescue dosing, Dr. Schneider said.

There is no evidence for major organ toxicity with opioids. However, constipation is a problem for virtually all patients, and they should be aware of the importance of adequate hydration to minimize this. A stool softener also may be of benefit, she said.

Opioids lower testosterone levels in men, which can put them at risk for osteoporosis. Dr. Schneider advised replacing the testosterone to prevent the loss of bone and to give men more energy and muscle strength.

The “big bugaboo” of opioid prescribing is diversion. “Are patients selling their drugs on the street? We all worry about this,” she said. To help guard against diversion, Dr. Schneider recommended doing routine drug screening with an additional screen for any special drugs that patients may be taking.

“A regular urine drug screen will pick up codeine, morphine, and heroin only, but not methadone, fentanyl, oxycodone, or hydrocodone. So when you use a urine drug screen, make sure you test for other drugs, if you suspect the patient is taking other substances.”

A drug screen is also good to make sure patients are using the drugs as prescribed, she added.

Dr. Schneider reported that she also has her patients sign a contract with her, in which they attest they will not engage in illegal or diversional activity and will take their medication in a responsible manner.

“If you do all these things and are victimized by someone who is a drug seeker, at least you have documented your efforts and have done everything you can do,” she said.

ORLANDO – Do not confuse addiction with physical dependence when prescribing opioids for your chronic pain patients, Dr. Jennifer P. Schneider advised at the annual clinical meeting of the American Academy of Pain Management.

Trust patients to tell the truth when they complain of pain and counsel them about the side effects of opioids.

Dr. Schneider, an internist whose Tucson, Ariz., practice focuses on addiction medicine and pain management, stressed that the patient's word is the gold standard when it comes to judging his or her own pain. However, she said, “Doctors are uncomfortable with this.”

The field of chronic pain management is full of misconceptions, she added. For example, cancer pain is more likely to get treated than noncancer pain, because practitioners falsely believe patients will become addicted to their pain medications; some physicians may not be concerned about the risk for addiction in this population because they perceive these patients as being close to death.

“This is such faulty thinking. Addiction is not the same as physical dependence or tolerance. We've got to get that message across to clinicians,” she said.

Sometimes physicians get suspicious when patients complain that their original dose either relieves pain less effectively than before or has stopped altogether, Dr. Schneider said. “When this happens, ask patients about their function. Maybe they are having more pain because they are no longer just sitting on the sofa, like they used to. If they are now able to get up and walk the dog or do gardening, they will need more medication. So don't just assume it's tolerance, or worse, that they are drug seeking. If you don't want them to get back to lying on the sofa, prescribe more.”

Long-acting opioids are preferable over shorter-acting agents, because they produce even blood levels and more stable pain relief. Short-acting drugs are more likely to cause a “buzz” as they get taken up by the brain. Patients also have to get up in the middle of the night to take short-acting opioids to keep their blood levels constant.

Short-acting drugs are useful for acute pain, however, and can also be used for rescue dosing, Dr. Schneider said.

There is no evidence for major organ toxicity with opioids. However, constipation is a problem for virtually all patients, and they should be aware of the importance of adequate hydration to minimize this. A stool softener also may be of benefit, she said.

Opioids lower testosterone levels in men, which can put them at risk for osteoporosis. Dr. Schneider advised replacing the testosterone to prevent the loss of bone and to give men more energy and muscle strength.

The “big bugaboo” of opioid prescribing is diversion. “Are patients selling their drugs on the street? We all worry about this,” she said. To help guard against diversion, Dr. Schneider recommended doing routine drug screening with an additional screen for any special drugs that patients may be taking.

“A regular urine drug screen will pick up codeine, morphine, and heroin only, but not methadone, fentanyl, oxycodone, or hydrocodone. So when you use a urine drug screen, make sure you test for other drugs, if you suspect the patient is taking other substances.”

A drug screen is also good to make sure patients are using the drugs as prescribed, she added.

Dr. Schneider reported that she also has her patients sign a contract with her, in which they attest they will not engage in illegal or diversional activity and will take their medication in a responsible manner.

“If you do all these things and are victimized by someone who is a drug seeker, at least you have documented your efforts and have done everything you can do,” she said.