Monday, August 10, 2015

The Opiate Escalation Trap: Why some patients fail opiate pain management

By : Ty Thomas, MD, with Alabama Pain Physicians

When a patient is prescribed high doses of opiate medication for chronic nonmalignant pain, most providers cringe and view that patient in a negative light. The provider then might go a step further and asks, “Who in their right mind prescribed this?”

In our current medical climate with opiates considered an epidemic, the practice of prescribing opiates for nonmalignant pain is dicey. The state board has done a good job educating providers about the basics of opiate prescribing and its associated rules and regulations. First on that list is “make sure you have a damn good reason to prescribe these first.” Second on that list is “not everyone with a good reason should get opiate medications.” The third thing is “if you do it, you better make sure you monitor them.” I paraphrase a bit, but, if you have been to any of these education sessions, this is how the message is delivered. I agree wholly with that message. However, that “good reason” often goes assumed and rarely fully interrogated to warrant a solid, soon to be extinct, 5 digit ICD-9 diagnosis code.

The purpose of this article is to take those 3 rules and add a caveat for those patients on high doses. When I see these patients, I ask, “Why did they require such an escalation for this?” High dose opiates are rarely indicated for nonmalignant pain at any stage. Tolerance is often the reason most providers and patients give when asked why. This makes sense to a degree. Mr. Smith has been suffering this pain for 15 years now. A little increase here and there adds up over time. However, there are medication management techniques to avoid this.

One of the escalation traps I see providers get stuck in is when the patient correctly or incorrectly perceives euphoria for pain relief. “Doc, this pain med just isn’t working as well as it used to.” Trying to explain the distinction between euphoria and pain reduction to someone can be like trying to recite beautiful poetry with a mouthful of marbles. It just doesn’t come out right. Besides, the euphoric feeling of an opiate sure goes a long way when trying to overcome the suffering of a perceived terrible pain. Tolerance to euphoria does develop quite quickly in some. This is the trap. As a provider, this distinction of euphoria vs. absence of pain is always in the decision making process when it comes to escalation or perhaps opiate cycling.

So this is my thought process: First, it is my policy to never escalate someone over 120 mg morphine equivalents daily for nonmalignant pain. Anything more increases the risk for serious adverse events by at least 6 fold depending on the study. So how do I overcome this? I start by making sure I have a solid diagnosis warranting an opiate as one of many tools to use to manage pain. I then make sure the patient is a solid candidate to responsibly take these medications--this is a topic in itself and complex. I monitor for patient compliance as much as I can (insurance changes have made this much more difficult lately—again, another topic). Then, I explore why someone might be incompatible for a specific opiate or delivery method. I also look for other reasons why someone might fail standard opiate therapy (requiring escalation beyond 100mg morphine equivalents daily).

These include:

• Opioid malabsorption

• Genetic defects

• Neuroinflammation

• Hormonal Deficiencies

In summary, most patients do not need or require high doses of an opiate for chronic nonmalignant pain management. If they do, patient aberrance is not usually the reason. Instead, there has likely been a failure to differentiate euphoria from pain relief leading to euphoria tolerance and or a failure to recognize why a patient has failed standard opiate dosing therapy as listed above. While complicated, time consuming, emotionally draining and frustrating at times, good, responsible, comprehensive pain management is possible even in this health care environment. If in doubt, refer the patient out—I will be happy to see these patients.

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