Wise Use

Prescribing Opioids Wisely: Strategies for helping your patients and avoiding problems with regulators

  1. Perform thorough physical exams and obtain complete histories of your patients to determine what causes the pain. Screen your patients for substance abuse. Ask for a complete list of medications, a list of all other physicians seen in the last two years and a list of all pharmacies used in the last two years. Get a baseline urine drug screen and read number 9 below.
  2. If a patient asks for a specific drug, don’t prescribe any drugs. This is a telltale sign of abuse.
  3. Chart everything. Every entry should be so detailed that it could stand alone if separated from the rest of the chart. Explain how you intend to follow them over time, what alternatives have been considered, and why you believe opioid analgesics will be helpful.
  4. Obtain informed consent so that there is no doubt about the treatment proposed. A goal oriented consent (agreement) is preferred. Your patients must agree that only you will prescribe controlled substances for their pain and that they will not go to the emergency room for pain medication without your permission.
  5. Get your patients to agree to use only one pharmacy and explain to the pharmacist why you intend to prescribe long-term opioids. Does the pharmacist have any concerns about your patients receiving opioids? Make certain that the pharmacy stocks the medications you expect to prescribe.
  6. Get a second opinion from a pain management specialist, a specialist in the organ system that is the source of pain, or a specialist in the overall disease process. Share the responsibility for prescribing opioid analgesics with another physician.
  7. Prescribe long-acting opioid analgesics to be taken on a regular schedule to achieve stable levels. Avoid "as needed" medications and use immediate -release medications only to cover periods of breakthrough pain.
  8. See your patients regularly and do regular pill counts. Document why your patients continue to need opioid medications. Avoid telephone prescriptions and do not give open-ended prescriptions with refills. Never refill for a lost prescription. If the patient states that the pills were stolen, refill only after a completed police report.
  9. Determine the minimum dose patients need to maintain daily activities by occasionally decreasing daily dosage by 25% to 35%. Discuss this strategy with your patient before decreasing the dose.
  10. Rule out drug diversion by documenting that you are able to recover the prescribed medication with a urine drug screen. Urine screens also show that you are alert to the patient's potential use of illicit substances. Obtain at least one, but strongly consider two or three random regular urine drug screens each year. A urine drug screen obtained at the time of an office visit is not random.
  11. Continue to receive opioid analgesic education by attending meetings and conferences such as the Annual Clinical Meeting of the American Academy of Pain Management
  12. Visit erowid.org. This is a commonly visited site for individuals interested in psychoactive plants, chemicals and related issues.