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■ Manual signature of prescriber

There is one factor that will remain constant for health care providers who treat chronic pain. Opioids will need to be used at some point for some patients. Learning the correct methods for safe opioid prescribing, such as safe prescription writing, will help the prescribing practitioner feel more comfortable with the process.

Opioids have been considered as a viable option for effective treatment of chronic pain for many years (American Academy of Pain Medicine & American Pain Society, 1997). When opioids are used to treat pain, the majority of patients taking the opioids do not become addicted. However, it has become increasing apparent that there is some risk of addiction in the general primary care patient population. How big the risk is cannot be fully determined with the current literature database. Some of the best data indicate that the risk of real addiction is low, <5% or 2%—5% of pain clinic patients. Even the best research in this area does not provide a definitive answer to the question of addiction in a general patient population.

There are some indications that the problem is real and increasing in significance. As the use ofopioids increased (as of2002 it is estimated that 4 to 6 million American patients were receiving opioids), 12% of all medications prescribed in ambulatory care office visits were noted to be opioids. During the same period, admission to substance abuse centers for narcotic (opioid) painkillers increased by 155% between 1992 and 2002, and the number of emergency room visits for narcotic (opioid) analgesic abuse increased 117% from 1994 to 2002.

The Substance Abuse and Mental Health Services Administration reported in a 2007 survey that 6.9 million persons used prescription drugs that were classified as psychotherapeutic in the past month, with opioids making up 5.2 million usages. Prescription drug abuse among teens has been steadily increasing over the past decade, despite advertisement campaigns to make parents and pharmacies aware of the dangers. Between the years 1992 and 2002, new opioid users increased by 542%; for college students, from 1993 to 2005, the number who reported opioid use in the past month increased by 343%. Despite these sobering statistics that indicate prescriptions are being misused, rates of addiction are not increasing by anywhere near the number indicated by the abuse statistics.

In one of the most recent findings, the incidence of addiction in a meta-analysis was 0.19% for a preselected group of patients who had never been exposed to opioids and 3.27% for a preselected group of patients who had a history of opioid abuse or addiction (Fishbain et al., 2008). In another study of 800 primary care patients being treated for a variety of pain complaints, the incidence of addiction for the overall group was found to be similar to other studies, where the addiction rate was between 4% and 6% (Flemming et al., 2007). In an analysis of addiction studies assessing the prevalence of addiction in chronic pain patients, the rates of addiction were found to be similar to the general population. This means that the vast majority of primary care patients in the studies were using their opioid medications correctly, with a select few developing true addiction.

In light of these findings, prescribers who are providing opioids for patients need to adopt practices that can protect prescribers from any inquiries into prescribing practices or regulatory review. Safe prescribing simply means that prescribing practices follow current national guideline recommendations, legal requirements, and use standard techniques for screening and continuing opioid therapy for patients who require long-term medication therapy. Using safe prescribing practice protects both the prescriber and the patient.

Screening tools are used when starting the patients on opioid therapy to determine the level of risk, if a patient on opioids is having difficulty managing the opioid therapy, and continued screening of the patient on opioid therapy is used to determine if aberrant behaviors are developing. Random urine screens are incorporated into the opioid treatment agreement that patients on opioid therapy should sign prior to initiation of long-term opioid therapy. The combination of urine screening, opioid treatment agreements, and screening tools should always be used together and not as a solo measure of risk assessment.

Clinical Pearl

What is a safe prescription?

■ A risk-benefit ratio analysis is included before a medication

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