Addressing ongoing opioid use at the office visit:
1) Assess benefits (Assessing Benefits)
- This should include review of the specific goal set out at the beginning. It may include revision of this specific goal to something else (e.g. goal of using treatment to garden not relevant in snowy winter months)
- Administer the PEG Pain Screening Tool
2) Determine how the patient is actually using their opioid.
- Take 24-hour inventory. (“Take me through a typical day of using your prescription.”)
- Sometimes we find that patients use the opioid for something other than pain. Is that happening to you? (e.g. “It helps me to go to sleep,” or “I take it when I am feeling down.”)
3) Review potential side effects: Sedation, Constipation.
4) Review emotional, psychiatric, social issues
5) Gather objective information:
1. Observe for signs of intoxication, withdrawal
2. Prescription Monitoring Program
3. Urine drug screen data
6) Information from reliable family members may be useful. Beware of family members who have incentive to provide misinformation for their own gain.
How to communicate next steps:
Minimal Side Effects/Risks
Significant Side Effects/Risks
|Partial or Full Goals Achieved||Continue current meds(continuing as test)|
|“We will continue the opioid at current dosing and monitoring. We will review your pain and goals at future visits to help us decide whether opioids will continue to help you without hurting you.”||“Although this medication appears to be helping you achieve your goals, I’m quite concerned about some of the side effects (or risks) of this medication. It is important that your medication is safe for you. The balance between the risks and the benefits is what determines whether this medication can be continued.”|
|Goals Not Achieved||“The opioid you tried did not help accomplish the goals we discussed at the last visit. (list the goals)”||“This opioid medication is not helping you accomplish the goals for the pain medication that we talked about. (list the goals)”|
|If the plan is to increase the dose as a test:“Let’s increase the dose to see if the problem was too low a dose. If that does not work, we will have to think of a different treatment option other than this medication. ”||If side effects have presented: “Besides that, it is causing side effects (name them).”|
|If the plan is to change to another opioid:“Let’s switch to a different opioid medication to see if it is more effective. Some people don’t respond to one medication but do get benefit from another one. If that does not work, we will have to think of a different treatment option other than this medication. ”||If risks have presented:“Besides that, when taking this medication, I’m concerned about some risks that have come up. These include (name them, E.g. your pill counts are consistently not accurate, the PMP shows you have been getting sedative medications from other doctors without my knowing)”|
|If the plan is to change from a short to a long acting agent:“Let’s try this same pain medication in a form that lasts longer. Remember that you might not feel the effects as soon after you take it as you do right now. If that does not work, we will have to think of a different treatment option other than this medication.”|
|If the plan is to stop the opioids, see How to Discuss Stopping Opioids|
- PEG Pain Screening Tool: A three question validated measure on average pain levels, pain-related disability and pain-related quality of life that can be used repeatedly to assess response to treatment.
Source: Krebs, EE., Lorenz KA., Bair MJ., Damush TM., Wu J., Sutherland JM., Asch JM., Kroenke, K. “Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. General Internal Medicine. 2009; 24(6):733-738.
- Anxiety assessment: An adaption of the GAD-7, a 7 question self-assessment tool used to assess general anxiety symptoms
Source: Spitzer, RL., Kroenke K., Williams JB. Lowe, B. “A brief measure for assessing generalized anxiety disorder: the GAD-7.” Archive of Internal medicine. 2006;166(10):1092-1097.