8 Prescribing Guidelines

Overdose deaths involving prescription drugs are rising, and the reasons are multifactorial. Data are incomplete, but good evidence points to several likely contributing factors. To minimize harm when prescribing opioids and other psychotherapeutics, observe the following guidelines:

  1. Assess patients for risk of nonmedical use or medical misuse before starting opioid therapy and manage accordingly

    Problem: Overuse of prescriptions has been shown to cause harm and may be a factor contributing to overdose deaths (1-2).

    Suggestion: Pain providers may use one of several available tools before prescribing for opioids ever takes place to assess patients for their risk of developing problematic drug-taking behaviors. Tools recommended by experts in the field include the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain (SOAPP)(3-4). If risk factors are revealed, implement a plan according to the level of risk: e.g., for high-risk patients, this might include referral for further psychological evaluation and co-management with a chemical dependency expert prior to initiating an opioid trial; for low-to-moderate but at-risk patients, a structured monitoring and close follow-up plan should be agreed upon, documented and followed. All patients, no matter how low the apparent risk, should be treated with “universal precautions,” modeled after the infectious disease paradigm (5).

  2. Watch for and treat co-morbid mental disease when it occurs

    Problem: Mental-health problems such as depression and anxiety disorders frequently occur together with chronic pain (6-7), causing some patients to misuse their analgesics or psychotherapeutic medications, or mix their medications with alcohol or illicit drugs to relieve emotional distress. These behaviors place the patient at high risk for drug-drug interactions and related toxicity.

    Suggestion: It is important to assess for the presence of mental-health disorders before initiating opioid therapy. When indicated, treating clinicians should consult with experts in mental-health fields to coordinate care. Patients with a dual diagnosis of chronic pain and psychiatric co-morbidity should be treated for both problems simultaneously. Patients sometimes independently seek care from multiple sources without volunteering this information; be proactive and seek out this information when taking a history at each visit. Know what is being prescribed and by whom to coordinate care and manage medication use as safely and effectively as possible.

  3. Conventional conversion tables may cause harm when rotating (switching) from one opioid to another

    Problem: Equianalgesic conversion tables provide insufficient guidance to determine the equivalent doses of different opioids (8-9). Their use in determining a safe and effective dose of a substitute opioid requires additional consideration for every patient’s individual circumstances.

    Suggestion: When rotating from one opioid to another, consider slowly decreasing one opioid while slowly titrating the new opioid to effect (10). This process takes time but may be safer than switching all at once. If you are not experienced in switching opioids in patients on long-term opioid therapy, seek consultation from a clinician with this expertise.

  4. Avoid combining benzodiazepines with opioids, especially during sleep hours

    Problem: Benzodiazepines will enhance the respiratory-depressant effects of opioids (11-12).

    Suggestion: When possible, consider using an alternative to benzodiazepines for anxiety disorders. When a sleep aid is indicated, avoid benzodiazepines and use alternative treatments, like an anticonvulsant or a low dose of trazodone. For a patient with a neuropathic pain disorder, a low dose of a tricyclic antidepressant at bedtime may be dually beneficial. Use caution in older patients, monitoring for excessive anticholinergic effects.

  5. Use methadone as a secondary or tertiary agent, starting with a low dose and titrating very slowly.

    Problem: Methadone's half-life averages from 8 to 59 hours but can last up to 130 hours in some people; compare this to its analgesic effect, which usually lasts only 4 to 8 hours (13-14). This unusual pharmacokinetic profile can contribute to an unpredictable accumulation of methadone during the first few weeks of treatment. Until steady state is reached, and especially during sleep, this is a time of particular vulnerability to respiratory depression.

    Suggestion: Consider starting patients (whether or not they are opioid naïve) on 10 mg or less per day (15), in divided doses (q8h) and increase total daily dose by no more than 25% to 50% no more frequently than weekly. If you are not experienced prescribing methadone, consult with a clinician who is.

  6. Assess for sleep apnea in patients on high daily doses of methadone or other opioids and in patients with a predisposition

    Problem: Research has shown a high prevalence of sleep apnea in patients on chronic opioid therapy (11, 16-17). The data suggest a dose relation, and the sleep apnea can be life threatening on moderate-to-high doses of opioids.

    Suggestion: Patients who require greater than 50 mg of methadone or greater than 150 mg morphine equivalent of other opioids should be referred for formal sleep apnea evaluation. So should those with a predisposition for sleep apnea (e.g.,“Pickwickian” physiognomy, history of snoring or apneic episodes reported by sleep partner). Home sleep studies are a viable option for initial evaluation, if cost is a factor. If sleep apnea is moderate-to-severe, seek consultation regarding the best treatment options. At-risk patients may require inpatient evaluation to monitor for and determine safety of opioid therapy.

  7. Tell patients on long-term opioid therapy to reduce opioid dose during upper respiratory infections or asthmatic episodes

    Problem: Respiratory infections or asthma attacks can decrease the margin of safety during long-term opioid therapy.

    Suggestion: Patients should be advised to reduce their daily opioid doses, particularly their evening doses, by at least 30% during events with acute respiratory tract compromise.

  8. Avoid using long-acting opioid formulations for acute, post-operative or trauma-related pain

    Problem: Long-acting or sustained-release opioids, including transdermal patches (18), were not designed to treat acute post-operative or trauma pain.

    Suggestion: These medications should be reserved for patients who have developed tolerance to opioids.

References

  1. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers---United States, 1999--2008. MMWR Morb Mortal Wkly Rep. 2011; 60(43):1487-92.
  2. Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. 1st ed. North Branch, MN: Sunrise River Press; 2007.
  3. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Med 2005 Nov-Dec; 6 (6):432-42.
  4. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004 Nov;112(1-2):65-75.
  5. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005 Mar-Apr;6(2):107-12.
  6. Ohayon MM, Schatzberg AF. Chronic pain and major depressive disorder in the general population. J Psychiatr Res. 2010 May;44(7):454-61.
  7. Manchikanti L, Giordano J, Boswell MV, Fellows B, Manchukonda R, Pampati V. Psychological factors as predictors of opioid abuse and illicit drug use in chronic pain patients. J Opioid Manag. 2007; 3(2):89-100.
  8. Knotkova H, Fine PG, Portenoy RK. Opioid rotation: the science and the limitations of the equianalgesic dose table. J Pain Symptom Manage. 2009; 38(3):426-39. Review.
  9. Webster LR, Fine PG. Review and critique of opioid rotation practices and associated risks of toxicity. Pain Med. 2012; 13(4):562-70.
  10. Webster LR, Fine PG. Overdose deaths demand a new paradigm for opioid rotation. Pain Med. 2012; 13(4):571-4.
  11. Webster LR, Choi Y, Desai H, Grant BJB, Webster L. Sleep-disordered breathing and chronic opioid therapy. Pain Med. Published article online: 30-Jul-2007 doi: 10.1111/j.1526-4637.2007.00343.x
  12. Mikolaenko I, Robinson CA Jr, Davis GG. A review of methadone deaths in Jefferson County, Alabama. Am J Forensic Med Pathol. 2002 Sep;23(3):299-304.
  13. United States Food and Drug Administration. Information for Healthcare Professionals: Methadone Hydrochloride. Rockville United States Food and Drug Administration; 2006.
  14. Eap CB, BuclinT, Baumann P. Interindividual variability of the clinical pharmacokinetics of methadone: implications for the treatment of opioid dependence. Clin Pharmacokinet 2002; 41(14):1153-93.
  15. Webster LR. Methadone-related deaths. J Opioid Manage 2005 Sep-Oct;1(4):211-7.
  16. Farney RJ, Walker JM, Cloward TV, Rhondeau S. Sleep-disordered breathing associated with long-term opioid therapy. Chest 2003; 123(2):632-639.
  17. Wang D, Teichtahl H, Drummer O, Goodman C. Cherry G, Cunnington D, Kronborg I. Central sleep apnea in stable methadone maintenance treatment patients. Chest 2005; 128 (3): 1348-1356.
  18. U.S. Food and Drug Administration. FDA public health advisory: important information for the safe use of fentanyl transdermal system (patch); Dec. 21, 2007.

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Media Coverage

November 16, 2012
Physicians take lead role in confronting opioid misuse, but still face hurdles: This is the second in a series exploring the intersections between effectively caring for people living with chronic pain and the rise in unintentional poisoning deaths due to prescription painkillers. (The first post is here.) The series will explore the science and policy of balancing the need for treatment as well as the need to prevent abuse and diversion. This week’s story looks at clinical efforts to reduce the risk of opioid abuse and overdose while still caring for patients; the next story will explore the role of public health officials in curbing opioid abuse. Read More

November 14, 2012
AMA webinar spells out 8 ways physicians can curb opioid misuse: The Association holds the first in a series of webinars to teach doctors more about appropriate pain management. Read More

September 17, 2012
FDA Warns of Serious Skin Burns from Topical Pain Relievers: FDA Warns of Serious Skin Burns from Topical Pain Relievers Read More

July 3, 2012
Methadone deaths may have peaked, feds say: CDC » Doctors are more cautious about prescribing methadone for pain because of federal, state warnings. Read More

April 9, 2012
Filling In the Gaps on Pain Prescriptions: Filling In The Gaps On Pain Prescriptions Read More

April 5, 2012
Opioid Rotation Practices Linked to Fatalities: Opioid Rotation Practices Linked to Fatalities Read More

April 3, 2012
Switching Opioids Increases Risk of Overdose Death, Study Says : Switching Opioids Increases Risk of Overdose Death, Study Says Read More

April 2, 2012
Changing Opioids Causing More Overdose Deaths : Changing Opioids Causing More Overdose Deaths Read More

April 1, 2012
Doctors kill thousands due to 'death tables,' Utah expert says in new study : Reference tool responsible in death toll from prescription painkillers Read More

April 1, 2012
Opiate conversion charts killing patients : Opiate conversion charts killing patients Read More

March 8, 2012
What Whitney Houston Teaches Us: Whitney Houston has died from an as-yet unknown cause, but prescription medications are rumored. Her struggles with substance abuse are well documented, because she honestly shared them with the public in hopes of finding her road back. Celebrity deaths bring to our attention the national public health crisis with prescription drugs, and the list is growing: Health Ledger, Anna Nicole Smith, Corey Haim, Mike Starr. These people are not apart from or above us but hold a mirror up to our own lives. Most healthcare practitioners and counselors know a client, a friend or even a family member who has met the same tragic fate. Read More

March 2, 2012
LifeSource Co-Founder Lynn R. Webster, M.D. Receives Inaugural AAPM Presidential Excellence Award for Education: The American Academy of Pain Medicine initiates award to honor Dr. Webster’s work on the AAPM Safe Opioid Prescribing Initiative. Read More

January 12, 2012
The Chronic Pain Problem : Millions of Americans are affected by debilitating chronic pain, and diagnosis and treatment remain a challenge. Read More

November 2, 2011
Study shows Utah a leading state in painkiller deaths : A new study shows that painkiller abuse has not only reached epidemic levels in the United States, but overdose deaths continue a disturbing rise. Read More

November 1, 2011
Prescription Painkiller Overdoses in the US: Overdose deaths from prescription painkillers have skyrocketed during the past decade. Read More

September 14, 2011
Family: Player died from methadone overdose: Family members say a North Carolina high school quarterback died after a big victory last month after accidentally overdosing on some of his grandmother’s pain medication. Read More

August 26, 2011
Dr. Webster Pain Med Safety Interview: Host: Dr. Brian Grieves Radio station # (715) 524-2194 About: Dr. Brian Grieves is a radio show host at WTCH-AM, an affiliation WOTE-AM, both radio stations at Wisconsin. Every Saturday he gives his professional advice on "Health Talk" to his avid listeners in Shawano. Prior to working as a chiropractor, Grieves earned his Bachelors degree from the University of Wisconsin, a doctorate degree from Northwestern College, and his Masters Degree in Public Health from the University of Massachusetts. Read More

June 30, 2011
Dramatic increase of prescription-drug abusers seeking treatment: Dr. Webster joins KCPP to discuss trends in prescription drug abuse. Read More

June 23, 2011
'Rapid detox' a quick fix for opiate addiction?: USA Today Read More

June 15, 2011
LIFESOURCE ANNOUNCES NEW STUDY FINDINGS AVAILABLE ON DEATHS RELATED TO PRESCRIPTION OPIOD THERAPY: Nonprofit organization strives to address one of the nation’s biggest healthcare problems Read More

April 27, 2011
American Pain Foundation Announces New NSAID and Acetaminophen Pain Medication Safety Module and Public Service Announcement for PainSAFE Read More

April 20, 2011
U.S. Aims to Reduce Overdose Deaths, But Will the New Plan Work?: U.S. Aims to Reduce Overdose Deaths, But Will the New Plan Work? By MAIA SZALAVITZ Wednesday, April 20, 2011     The Obama administration announced on Tuesday a new initiative to reduce prescription painkiller Read More

April 19, 2011
Striving Toward Quality Pain Management: The epidemic of untreated chronic or recurrent pain has lasted for decades, yet millions of people are still not adequately treated. One significant barrier to effective pain management is that clinicians and patients are often reluctant to talk about pain... Read More

April 11, 2011
National Prescription Drug Abuse Expert From Utah To Present At Public Town Hall Meeting In Reading: Medical experts and law enforcement provide insights on adolescent prescription drug addiction Read More

March 22, 2011
National Prescription Drug Abuse Experts To Meet With White House Policy Makers: Experts will address prescription pain medication misuse and accidental overdose deaths with the White House Office of National Drug Control Policy Read More

March 10, 2011
National Prescription Drug Abuse and Overdose Deaths Expert Addresses Healthcare Professionals In Houston: Lynn R Webster, M.D. Read More

February 12, 2011
For Some Troops, Powerful Drug Cocktails Have Deadly Results: February 12, 2011 This article was reported by James Dao, Benedict Carey and Dan Frosch and written by Mr. Dao.   In his last months alive, Senior Airman Anthony Mena rarely left home without a backpac Read More

February 5, 2011
There are ways to help, prevent prescription drug abuse:   CHARLESTON, W.Va. -- Recently The Charleston Gazette ran a series on the emerging epidemic of prescription drug abuse. In a state with the highest rate of drug-related deaths, highlighting prescription drug abuse is an important public Read More

January 24, 2011
Morphine/Oxycodone Combination Superior to Separate Components: Montreal Read More

January 20, 2011
I Am An Addict:   Millions of older Americans are making this confession. Families are being torn apart. The good news: There's help Clean and sober for more than five years, Ron Dash has rebuilt his marriage and his life. “When I saw what Read More

January 10, 2011
Patients suffer when doctors are too scared to prescribe pain pills : Patients suffer when doctors are too scared to prescribe pain pills Monday, January 10, 2011; 8:36 PM    Every American should be concerned about the kind of message sent by the Jan. 2 front-page article "Doctors who pre Read More

December 15, 2010
Chronic pain patients, providers get new website:       Kathy Hahn Read More

December 9, 2010
Should an Overdose Antidote Be Made More Accessible?:   I've been writing about naloxone — the antidote to overdose of heroin, oxycodone or similar drugs — for more than 10 years, most recently for TIME here. The dru Read More

November 9, 2010
Addiction to painkillers hobbles more patients : ST. LOUIS — Nichole Marie Case unwittingly became dependent on opioid painkiller drugs. She's not alone. The National Institute on Drug Abuse estimated in 2008 that 1.85 million people in the United Stat Read More

October 25, 2010
Opioid safety is focus of $1 million-a-year educational initiative :   Opioid safety is focus of $1 million-a-year educational initiative Industry-supported PainSAFE targets how physicians and patients can avoid abuses and misuses of pain treatments. A group that represents patients living with pai Read More

February 11, 2010
The Effect of Academic Detailing on Curbing Opioid-Related Deaths in Utah

February 11, 2010
Root Cause Analysis for Unintentional Overdose Deaths Involving Opioids in Chronic Pain Patients Reveals Disproportionate Methadone Involvement

February 11, 2010
Costs of Oral Pain Medications Pre-IT Pump Implantation Compared to Post-IT Pump Implantation: A Retrospective Analysis

February 11, 2010
Select Medical-Legal Reviews of Unintentional Overdose Deaths

February 11, 2010
Comparison Of The Theoretical Cost Of Morphine And Prialt

November 18, 2009
To Help Healing, Doctors Pay More Attention to Pain. Morning Edition. National Public Radio.: The old notion that pain is somehow "good" for you should be put to rest for good, say health officials. They are increasingly recognizing that control of pain leads to more rapid recovery for hospitalized patients, and can even cut costs. Read More

November 28, 2006
National Expert from Utah Spearheads Educational Campaign: FDA Issues Methadone Warning: Providing Safe Access to Pain Medications. SALT LAKE CITY, Utah – November 28, 2006 – The Food and Drug Administration issued a warning yesterday to healthcare profe Read More

October 24, 2006
Prescription Medication Deaths Are On The Rise: Six Steps You Should Know: National Expert Calls for "Zero Unintentional Deaths" with Brigham City Physicians  SALT LAKE CITY, Utah – National pain medicine expert Dr. Lynn R. Webster will present his education campaign entitled Read More

October 18, 2006
Local Pain Medicine Specialist Calls for Zero Unintentional Deaths: National Education Campaign Comes to Brigham City Community Physicians. SALT LAKE CITY, Utah – October 18, 2006 – Dr. Lynn R. Webster, President of the Utah Academy of Pain Medicine and Medical Directo Read More

October 18, 2006
National Expert Calls for Zero Unintentional Deaths: National Expert Calls for "Zero Unintentional Deaths" with Hawaiian Physicians SALT LAKE CITY, Utah – National pain medicine expert Dr. Lynn R. Webster will present his education campaign entitled “Zero Unintentional Overdose D Read More

September 27, 2006
Methadone Related Deaths On The Rise : Six Steps You Should Know SALT LAKE CITY, Utah – Dr. Lynn R. Webster, President of the Utah Academy of Pain Medicine and Medical Director of Lifetree Clinical Research® & Pain Clinic in Salt Lake City, announces six steps to avoid acci Read More

September 20, 2006
Local Pain Medicine Specialist Calls for Zero Unintentional Deaths: Statewide Education Campaign Goes National SALT LAKE CITY, Utah – Dr. Lynn R. Webster, President of the Utah Academy of Pain Medicine and Medical Director of Lifetree Clinical Research® & Pain Clinic in Salt Lake City, announced that h Read More

September 18, 2006
Local Pain Medicine Specialist Calls For Zero Unitentional Deaths: National Education Campaign Comes to St. George Community SALT LAKE CITY, Utah – Dr. Lynn R. Webster, President of the Utah Academy of Pain Medicine and Medical Director of Lifetree Clinical Research® & Pain Clinic in Salt Lake City, a Read More

June 8, 2006
Dr. Lynn R Webster Kicks Off Statewide Education Campaign: LOCAL PAIN MEDICINE SPECIALIST CALLS FOR ZERO UNINTENTIONAL DEATHS SALT LAKE CITY, Utah – Dr. Lynn R. Webster, President of the Utah Academy of Pain Medicine and Medical Director of Lifetree Clinical Research® &a Read More

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