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Implementing Strategies for Safe Use of Pain Medications

  • Authors: Roger Chou, MD; Michael R. Clark, MD, MPH, MBA
  • CME Released: 10/11/2012
  • Valid for credit through: 10/11/2013
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Target Audience and Goal Statement

This activity is intended for primary care physicians and neurologists. There are no prerequisites.

The goal of this activity is to disseminate best practices to facilitate and enhance the safe use and appropriate prescribing of pain medications.

Upon completion of this activity, participants will demonstrate the ability to:

  1. Summarize effective and safe pain treatment strategies that have been shown to reduce the risk for abuse, misuse, and diversion of prescription medications
  2. Outline strategies for helping patients to take action to reduce the risks for abuse, misuse, and diversion of prescription pain medications


The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings and adverse effects, before administering pharmacologic therapy to patients.

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Faculty and Planning Committee

  • Roger Chou, MD

    Associate Professor, Department of Medicine and Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland


    Disclosure: Roger Chou, MD, has disclosed no relevant financial relationships.

    Dr Chou does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Chou does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Michael R. Clark, MD, MPH, MBA

    Associate Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine; Director, Pain Treatment Program, Johns Hopkins Hospital, Baltimore, Maryland


    Disclosure: Michael R. Clark, MD, MPH, MBA, has disclosed no relevant financial relationships.

    Dr Clark does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Clark does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

    Participation by Dr Clark in the development of this product does not constitute or imply endorsement by the Johns Hopkins University or the Johns Hopkins Hospital and Health System.

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  • Sarah Williams, PhD

    Scientific Director, Medscape, LLC


    Disclosure: Sarah Williams, PhD, has disclosed no relevant financial relationships.


  • Carol Cadmus

    Senior Clinical Editor, Medscape, LLC


    Disclosure: Carol Cadmus has disclosed no relevant financial relationships.

Content Reviewer(s)

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC


    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

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Implementing Strategies for Safe Use of Pain Medications

Authors: Roger Chou, MD; Michael R. Clark, MD, MPH, MBAFaculty and Disclosures

CME Released: 10/11/2012

Valid for credit through: 10/11/2013



Opioid analgesics can be a valuable part of the management of pain in some patients, but, as you are well aware, they are associated with many risks, including addiction, abuse, overdose, and diversion for nonmedical uses. Fortunately, there are strategies for minimizing these risks. Michael R. Clark, MD, MPH, MBA, spoke with Roger Chou, MD, about these safe use strategies, specifically in the context of managing non-cancer-related pain. Dr Clark is associate professor in the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, and director of the Pain Treatment Program at Johns Hopkins Hospital in Baltimore. Dr Chou is associate professor in the Department of Medicine and the Department of Medical Informatics & Clinical Epidemiology at Oregon Health & Science University in Portland.

Michael R. Clark, MD, MPH, MBA: The use of chronic opioid therapy clearly has its controversies, as well as its risks and benefits. Let's start at the level of the patient: is there a particular patient profile that represents an ideal candidate for opioid therapy?

Roger Chou, MD: Patient selection is one of the critical aspects of making opioid use safer. It involves selecting patients whom we think are going to do well in terms of benefits and are not at high risk for the harm related to opioids. I do not know whether there is an ideal candidate, but I would much more strongly consider using opioids in patients who have a relatively well-defined chronic pain condition -- for example, osteoarthritis of the hip or knee -- and who do not have psychological comorbidities, such as depression or past or present substance abuse.

Also, you want to select patients who are able to cope with their pain so that they will use the medication as part of an overall treatment strategy, not as the primary or only treatment for the pain. Patients who expect the pain medication to take all their pain away tend to be those who end up escalating their opioid doses and not getting the results you would like.

Clinicians often forget that family history is an important predictor of substance abuse; even patients who do not have a personal history of substance abuse can be at risk because of their family history, so it is important to ask about that.

It also is important to consider potential harm other than the harm related to abuse and addiction. These include effects on cognitive status, constipation or other gastrointestinal problems, and worsening of sleep apnea. Those effects can put people at higher risk as well and may be relative contraindications.

Dr Clark: You mentioned the term "well-defined chronic pain condition." How do you know where to draw the line on that continuum between a very clear-cut condition, such as diabetic peripheral neuropathy or chronic osteoarthritis, and the more vague syndromes, such as chronic low back pain, or others that have more descriptive terms?

Dr Chou: It is not an easy distinction to make, and in some ways, it is an artificial distinction. At one end of the spectrum, there are people who have somatization, who have pain that does not fit any kind of clinical condition or anatomic distribution, and they have a psychological component on top of that. In contrast, some patients have a fairly well-defined pain syndrome, in which they have arthritis with pain isolated to the knee or the hip. There can be radiologic evidence of degeneration, and no somatization or pain in other sites or overlying psychological issues. A number of conditions are difficult to define and may range from relatively straightforward pain conditions to quite complex presentations. Low back pain is a good example of that. I have had relatively straightforward cases of low back pain, and I have had others that are extremely complicated. You have to take the whole clinical picture into consideration. You cannot rely on imaging tests for back pain or fibromyalgia, but they do provide some additional information.

I also look for information about how the patient is functioning and how the patient is coping with the pain, in addition to the assessment of risk factors for abuse and addiction. All of these variables help build your picture so you can understand the patient and make a more informed decision.

Unfortunately, primary care providers are not always trained well to do this assessment. We have tried to address this with guidelines and other efforts to help people do more thorough assessments in order to make better treatment decisions.[1]

Dr Clark: For the busy primary care providers who have many patients, perhaps half of whom have a chronic pain problem, what do you think is the best approach to assessing these risk factors? Would you recommend that they use specific tools, or would you tell them to rely more on their general interviewing skills and make sure that they cover the important domains?

Dr Chou: We do recommend using a formal tool because it helps clinicians document the assessment, which is very important both for clinical care as well as for medicolegal reasons (Table 1). Some of these tools have been validated, and we have some information that they help predict aberrant behaviors. So there is some evidence to support using these tools.

Table 1. Examples of Opioid Risk Assessment Tools

Opioid Risk Tool[2]
Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R®)[10]
Diagnosis, Intractability, Risk, Efficacy (DIRE) risk assessment tool[11]
Pain Medication Questionnaire[12]
Screening Tool for Addiction Risk (STAR)[13]
Screening Instrument for Substance Abuse Potential (SISAP)[14]

One of the simpler tools that many groups have adopted is the Opioid Risk Tool developed by Lynn Webster.[2] It is a straightforward tool. It has 5 criteria, and you basically just add up points to get a risk score. One of the nice features of the Opioid Risk Tool is that it is not as dependent on getting a reliable self-reported history. Some of the other tools are patient self-administered and ask almost leading questions about prior substance abuse or problems with medications, whereas the Opioid Risk Tool is based on historical and demographic factors, such as age, family history, and psychological history, so it may be a little less subject to manipulation. It is easy to use, and I think it is helpful.

Clinicians still need to know about the risk factors and use their clinical judgment as well. But if clinicians routinely used this tool, they would make more-informed decisions.

Dr Clark: Yes, and you make an important point that it is not "either-or" -- the tool or the interview. It is both. It is nice to have the tool, but you still need to have expertise in its use.

Dr Chou: Also, the score does not necessarily tell you what to do. Many patients end up in the moderate risk category -- for example, they may have had an alcohol problem in the past. You still need to apply clinical judgment in terms of how you are going to manage that patient. If you decide to use an opioid, you need to use that information to come up with a treatment and monitoring plan to mitigate any potential risks.

Dr Clark: When you begin prescribing opioids for a patient and are concerned about some risk factors, what would you say to the patient about those risk factors and how they fit into your decision to prescribe opioids? I am assuming that you would want to establish measurable or functional goals with patients so that they know what the targets are for defining success with this therapy.

Dr Chou: Yes. When discussing the risk factors, it is important to be up-front with patients and tell them if they are at higher risk for having problems with opioids and explain it in terms that focus on safety. The reason for this is that these medications can be quite dangerous. As we all know, there are many accidental overdose deaths associated with opioids. Some people have gone so far as to label it an epidemic of prescription opioid overdose deaths. So, we need to take this seriously. It is very important to be clear with patients that if you are starting to take opioids, the first month or 2 is a trial period and that the decision may be made to stop use of the opioid medication if the patient does not appear to be benefiting or if there are signs that the patient cannot manage the opioid appropriately or is having other problems with it.

It also is important to lay out for the patient how you are going to use the opioids and how you are going to monitor for side effects. Some patients may find that the monitoring makes them feel as though they are being treated like a criminal, but the way I present it is that it is like going to the airport: everybody has to go through security. It is a safety issue, and we treat everybody the same way. We make sure that patients understand that they need to take the opioids as prescribed, that we are going to use urine drug tests periodically to make sure that they are taking the prescribed medication and not other unprescribed opioids or illicit substances. We let them know that we are reviewing their prescription drug monitoring program data, which can tell us if they are obtaining medications from other venues and is a risk factor for accidental overdose. We have them come in for regular follow-up clinic visits. It is important for us to be able to assess how they are doing to continue use of these medications.

All of these steps can help determine which patients benefit from opioids and which ones do not. One of the lessons that we have learned with opioid prescribing is that many patients do not seem to benefit very much, if at all, and many patients run into problems with the medicines. It is important to understand that it is often in the patient's best interest to stop using the medicine if he or she is not getting any benefit or is having problems.

Assessing the functional goals is one way to determine whether the opioid medication is helping. You do not want to rely only on the pain scores. Pain levels are important, but if patients say that their pain is better but their functioning has not improved, that response is not as good as having improvement in both pain and function.

To assess functional goals, you need to define achievable and measurable goals. It is not realistic for a patient who is 65 years old to say "I want to feel like I did when I was 30." It may not be reasonable for that person to want to run a marathon, but gardening 4 or 5 times a week for 30 minutes a day or walking the dog for 20 or 30 minutes daily may be an achievable goal. Even going out to the mailbox every day is a positive step for some people. For others, the goals may be tied to work- or family-related functions. The key is to find out what is important to the patient and then develop measurable targets that will help you assess whether progress is being made.

Dr Clark: So you talk to patients about what they are doing in their lives and what they would like to be doing more of, and you tailor the functional goals to the individual patient?

Dr Chou: Yes, exactly. The goals should be meaningful and important to the patient. When you follow up, you might say, for example: "You've been taking this medication for 4 months, but you still cannot go to your child's soccer games, and you said that was the most important thing for you to be able to do." This helps clarify the role of the opioid and the role for other strategies that may be used to help manage the patient's pain and improve the patient's functioning.

My perspective is that opioids do not address many of the things that need to be addressed to improve function in patients with chronic pain. Opioid medications should be part of an overall plan that includes other strategies, such as physical therapy, a regular exercise program, and learning coping strategies.

Dr Clark: I could not agree more that the medication should be just one component of a plan of therapy. What do you say to the patient who says "I've tried everything that you've suggested. I just want to be comfortable, and if you would make me comfortable, there's a much better chance that I would do these things. I really want to, but I just can't, so why don't you just give me the medicine?"

Dr Chou: There may be some truth behind that perspective, but that does not mean that I would give up on those other strategies. It is still important to emphasize, for example, cognitive-behavioral principles and coping strategies. It may be okay to start using an opioid in conjunction with some of these other strategies, but we still want to be able to see some measurable progress in terms of a patient's functional capacity.

There certainly is an art to managing patients with chronic pain. Part of that is setting expectations and having a collaborative treatment plan that requires that the patient participate. It's their pain. I try to emphasize that I am here to help them manage their pain and become more functional, but I cannot do it on my own.

Dr Clark: When you are monitoring patients, do you use the same process for everyone, or do you tailor your monitoring for aberrant drug-taking behaviors depending on the patient's risk factor profile?

Dr Chou: I do tailor it a bit. There are some universal steps, such as having them come in for periodic follow-up, but the duration between follow-up visits can vary. Some higher-risk patients come in every week or every few weeks, while others can come in every 3 months or even 6 months if they are at low risk, have had stable doses, and have no signs of aberrant behaviors. This also applies to urine drug testing and other measures, which can be quite expensive. I do not believe that low-risk patients need to have urine drug testing at every or nearly every visit, whereas in a high-risk patient that might be indicated. However, some low-risk patients end up being the ones who are abusing or diverting medications, so people can get fooled, and we have to very aware of that. This is why we cannot totally abandon monitoring.

Dr Clark: Are there particular methods or sources of information that you use for educating patients and their families about these medications?

Dr Chou: Yes. A number of groups provide this kind of patient education. I led the development of a guideline that was published by the American Pain Society and the American Academy of Pain Medicine,[1] and both of those organizations have patient materials. We also worked with the American Chronic Pain Association, which is a patient group that has developed patient educational materials as well. The website also provides some useful information.[3] (People should be aware that is sponsored by pharmaceutical companies.) Patient information also is available on federal websites, such as those of the Centers for Disease Control and Prevention),[4] Substance Abuse and Mental Health Services Administration,[5] and National Institute on Drug Abuse.[6] All of those groups have information that can be useful.

There also are some good books that are very helpful for patients. The one that I often recommend to patients is coauthored by Dennis Turk and Frits Winter -- The Pain Survival Guide: How to Reclaim Your Life.[7] This helps people with coping strategies, understanding what chronic pain is and how they can manage it. You can even use these books to test how engaged patients are in their plan of care. If you ask them to read a chapter, and they do not do it, that may be a clue that the patient is not highly engaged in his or her care.

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