Recognizing and responding to the fears that prescribers have when prescribing opioids, a new guideline for chronic opioid therapy (COT) has been developed by the APS in conjunction with the American Academy of Pain Medicine. This guideline highlights and addresses some of the problem areas that prescribers in primary care face on a daily basis. The multidisciplinary panel that developed the COT guideline lists the following recommendations for practice when COT is being considered:
■ Conduct a full history and physical examination, including diagnostic testing, and an assessment for the risk of substance abuse and misuse or addiction prior to initiation of the therapy.
■ Perform a risk-benefit analysis to analyze benefit to harm for moderate to severe pain and assess for function and quality of life prior to beginning opioid treatment.
■ Obtain informed consent and establish a COT management plan that includes documentation of a discussion with the patient on treatment goals, expectations, potential risks, and alternatives.
■ Individualize the medication dose and titration when doing a COT trial.
■ Prescribe methadone carefully, with initiation and titration being carried out by clinicians familiar with its use and risks.
■ Regularly reassess patients on COT and document urine screening, pain intensity ratings, functionality, progress toward identified goals, adverse events, and compliance with the prescribed regimen.
■ Perform a full assessment when aberrant behaviors, dose escalations, and high dose prescriptions occur, or when opioid rotation is considered as an option.
■ Place high-risk patients on COT only when monitoring parameters can be maintained and assistance from addictionologists or mental health specialists is available.
■ Counsel patients who are on COT to avoid driving when impaired.
■ Prescribe minimal or no opioids for pregnant patients, unless the potential benefits outweigh the risks.
■ Include a multidisciplinary team for COT and include functional restoration, psychotherapeutic interventions, and other nonopioid therapies. (Chou et al., 2009; D'Arcy, 2009b).
Conforming to the recommendations in the COT and LBP guidelines will help provide positive outcomes for patients while protecting the practice of the prescribing practitioner.
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