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Tuesday, October 4, 2011

Long-term Opioid Therapy


"Guidelines for long-term opioid therapy 
should not be developed by the field of pain medicine alone. 
Rather, experts from general medicine, 
addiction medicine, 
and pain medicine 
should jointly reconsider 
how to increase the margin of safety." 

(Michael Von Korff, ScD, Group Health Research Institute, 
"Long-term Opioid Therapy Reconsidered," Annals of Internal Medicine
American College of Physicians, 2011) 

 An epidemic of opioid abuse and overdose exists. Michael Von Korff and his team of researchers report: "Given the warning signs and knowledge gaps, greater caution and selectivity are needed in prescribing long-term opioid therapy. Until stronger evidence becomes available, clinicians should err on the side of caution when considering this treatment."

Clinicians and their professional societies can take action now to increase the margin of safety for patients and society. 

How about the public? What should everyone know about long-term opioid therapy? Knowledge of the risks of therapy can prevent adverse effects and save lives. A series of questions in this blog entry may increase general understanding and help ensure public safety. Here are some questions concerning long-term opioid therapy related to both the physician and the patient. Before entering into such treatment, a person may want to seek many answers.  

Questions About the Physician

1.Does the physician advocate acute pain management strategies that reduce the chance of unplanned transitions to long-term use of opioids?

2. Does the physician practice careful patient selection before initiating long-term opioid therapy?

3. Does the physician advocate strategies acknowledging that long-term opioid therapy entails medical, psychosocial, and addiction risks that need to be disclosed and managed? 

4. Does the physician adhere to recommended opioid prescribing practices?

5. Does the physician practice judicious opioid prescribing, particularly increased caution with higher doses?

6. Does the physician conduct proper monitoring of opioid treatment? 

7. Does the physician practice increased caution in opioid dose escalation?

8. Does the physician taper and discontinue long-term opioid therapy in patients who do not benefit from it or who seriously misuse opioids?

9. Does the physician care to limit the amount of opioid medication in the community, decreasing the potential for diversion?

Questions About The Patient

1. Are all the patient's medications managed by a single physician?

2. Has the patient completed a clinical risk evaluation?

3. Has the patient completed a treatment agreement? 

4. Has the patient completed urine drug screening?

5. Has the patient had all treatments documented in his/her medical record?

Until we better understand how to ensure the safety of long-term opioid therapy, gaps in knowledge and uncertain risks must be carefully considered. At present, physicians need to be selective, cautious, and vigilant when considering long-term opioid therapy. Lives depend on it.

Read the entire article: "Long-Term Opioid Therapy Reconsidered" -- http://www.annals.org/content/155/5/325.full#T1
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