Risks vs. benefits

Q&A: What physicians need to know about safe opioid prescribing

Katherine Galluzzi, DO, explains how physicians can weigh the risks and benefits of treating pain with opioids.

With prescription opioid overdose deaths in the U.S. surging to more than 14,000 in 2014, according to the Centers for Disease Control and Prevention, physicians need to understand how to balance the potential risks and benefits of opioid medications.

That’s where Katherine Galluzzi, DO, comes in. She’s a member of the Collaboration for REMS Education (CO*RE) content development team, which has developed continuing medical education based on the FDA’s risk evaluation mitigation strategy (REMS) for extended-release and long-acting (ER/LA) opioid analgesics.

Katherine Galluzzi, DO

In this edited Q&A, Dr. Galluzzi shares key points from the AOA and CO*RE REMS webinar ER/LA opioid REMS: Achieving safe use while improving patient care.

“DOs must work together to strike a balance between protecting the public from the scourge of opioid addiction while also securing access for patients in pain who truly stand to benefit from the thoughtful and cautious use of opioids,” she says.

When should physicians consider treating patients with opioids?

Short-term opioid treatment can be useful for patients who experience severe pain following a surgery or traumatic injury and aren’t able to find relief from other analgesics.

For patients with chronic pain, however, the FDA recommends that opioid therapy be used only if pain is severe and hasn’t responded to other interventions. The decision must involve shared decision-making between physician and patient, informed consent, and a formal patient-prescriber agreement.

As with most illnesses, the most effective treatment for chronic pain is thoughtful, multimodal therapy that combines physical and psychological interventions with prudent pharmacologic strategies.

When treating chronic pain patients, it’s also important to keep in mind that there are risks associated with long-term use of other types of painkillers, which can include hepatic and renal toxicity, gastric bleeding and cardiac side effects.

How can physicians assess and monitor patients for possible opioid abuse?

Physicians can use tools such as the opioid risk tool (ORT) or the screener and opioid assessment for patients in pain (SOAPP) to assess whether the benefits of opioid therapy are likely to outweigh the harms.

Through regular office visits, physicians can monitor patients receiving chronic opioid treatment to evaluate:

  • How the patient’s function has improved or declined.
  • Whether the underlying painful condition has improved.
  • The presence of red flags, such as the inability to keep a job, relationship problems or ongoing psychological issues.

Patients receiving chronic opioid treatment should also undergo random urine drug testing as part of routine follow-up care.

Physicians can check whether patients are adhering to the patient-provider agreement for opioid treatment by visiting their state’s prescription drug monitoring program. If a patient has a past history of addiction or is displaying red flag behavior such as “doctor shopping” or trying to fill prescriptions at multiple pharmacies, you may refer him or her to a pain management specialist.

How should opioid medications be stored, and how should leftover drugs be disposed of?

A locked cabinet is the best place to store opioid medications. Unused medications are best disposed of by taking them to a local drug take-back program or a collector authorized by the Drug Enforcement Administration. The FDA recommends flushing unused opioids down the toilet if other disposal options aren’t available, but some states, such as California, discourage this practice. Unused opioid medications may not be returned to the physician’s office.

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