As with all treatment options, there is a risk—benefit analysis that should take place before the option to treat the patient's complaint is chosen. When the main treatment focus is chronic pain and opioids are being considered, the analysis must take a wider view that incorporates all aspects of the patient's lifestyle. In today's press, the issue of undertreated chronic pain is becoming a frequent topic of conversation and debate. On the other hand, the information on increasing opioid abuse, misuse, and prescription fraud provides a counterbalance to the discussion. Where does this leave the primary care pre-scriber who cares for the majority of these patients?

As discussed previously in this book, there are barriers that prevent health care practitioners from prescribing opioids. For nurse practitioners (NPs), some major concerns with traditional (scheduled) opioid use in the treatment of chronic pain include the fear of physical dependence and addiction, which may result in the underusage of opioid analgesics, use of non-opioid analgesics when opioids are indicated as with severe level pain, and in prescriptions written at suboptimal doses. In addition, fears regarding legal ramifications of prescribing long-term opioid therapy may be allayed by recent reports showing the low risk of Drug Enforcement Administration (DEA) sanctions. In fiscal year 2003, 50 physicians (0.005% of all physicians registered) were arrested for activities that were knowingly and intentionally beyond the scope of medical practice. Administrative sanctions, as opposed to criminal investigations, are used for allegations of faulty record keeping, and in fiscal year 2003, 67 such actions occurred. There is no record of any litigation against an NP involving controlled substances or prescribing practices although there has been a case of voluntary surrender of a license by an NP involving prescribing of controlled substances. In addition, state laws and policies regarding opioid use are showing a trend toward adopting laws or guidelines that specifically recognize the use of opioids to treat intractable pain. Intractable pain treatment acts have been established in some states and are being established in others.

The newest recommendation by the U.S. Food and Drug Administration (FDA) is the requirement that drug companies provide risk management sheets, also known as a Risk Evaluation and Mitigation Strategy, for all opioids. These documents will provide a good risk—benefit assessment for many of the most common opioids and will help prescribers determine which medication will provide the best pain relief with the lowest risk profile. These documents should be available when they are developed on the FDA website. Currently the FDA has rejected some early attempts at REM development for opioids and revision to the documents is in process.

There are techniques and practices that can provide an element of comfort for health care providers prescribing long-term opioids for treating painful chronic conditions. For these patients and providers, setting up safe prescribing practices and using opioid agreements to clarify the goals and expectations of opioid use is good practice. The following section will describe safe prescribing practices and provide examples of screening tools and documentation forms that can assist with providing a safe environment for opioids prescribing.

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