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OPIOID CRISIS

For example, superficial heating is a simple, safe and usually effective azepines and opioids concurrently due to increased risk of accidental
treatment for low-back pain (7). Some available patient literature overdose. At the minimum, rationale for co-administration of these
shows heat treatment speeds recovery from back injury (8). Thera- two drug classes should be very well documented and managed by
pies that are safe, patient-applied and minimally expensive should al- pain specialists, if possible. As opioids are widely needed and preva-
ways be preferred, because more expensive treatments may yield no lent in clinical practice, physicians are exposed to potential liability
better results. or reprimand if prescribing practice falls well outside the intent of
the DEA and state agencies to limit the diversion of prescription
When drugs are needed for more distressing or debilitating pain, medications, which are the leading source of drug abuse and drug
providers should consider the wide array of classes and the pain re- overdose fatalities in the US (9).
ceptors upon which these drugs act (Table 1). For example, mem-
brane-stabilizing medications like carbamazepine are more specific for Fortunately, the bar for demonstrating responsible prescribing is
neuropathic pain conditions like trigeminal neuralgia. While opioids very achievable with proper knowledge and processes. Peer reviewers
could also work, they would probably be less efficient. Yet severe pain are much less likely to find fault with a practitioner who documents
from a long bone fracture would probably need a base therapy of opi- well the rationale and monitoring steps taken for a patient on opioids.
oids in conjunction with other techniques. If well tolerated, using “ad-
junctive” medications in conjunction with opioids can improve the If a judicious practitioner chooses to prescribe opioid therapy for
durability of the therapy and operate in therapeutic windows of both chronic pain management (chronic opioid therapy), there are several
(or more) pain medications. Also, the patient may be a candidate for steps that should be taken in order to meet the standard monitoring
referral to a pain specialist or surgeon for definitive treatment or in- process. Many of these are documented in Chapter 170 of the Texas
terventional pain procedures such as joint or spine injection. Medical Board Rules, the CDC Guidelines for Opioid Prescriptions
and other published guidelines for urine drug screens (10, 11, 12).
RATIONAL STRATEGY FOR OPIOID USE: These processes occur first with the evaluation, which should include
A CYCLE OF EVALUATION AND MONITORING obtaining all pertinent medical records, a thorough history and phys-
ical examination, ordering of necessary laboratory and imaging stud-
There are many reasons why opioids will be necessary for pain ies, and consultation or referral to a specialist if necessary. Once the
management. Some pain conditions are so severe in intensity that evaluation is complete, the patient should sign a “Controlled Sub-
opioids are needed even in the presence of comprehensive multi- stance Agreement,” or CSA, with the prescriber. This should outline
modal therapy. Sometimes clinicians become part of a medical con- the risks associated with prescription of opioids and the rules that
tinuity of pain care because
patients may have been estab- continued on page 22
lished on opioids in a recent hos- visit us at www.bcms.org 21
pitalization or the clinician inherits
the patient from another practice.
At other times, patients may be
specifically referred for manage-
ment of opioid therapy. Opioids
are considered controlled sub-
stances by the Drug Enforcement
Agency (DEA) because they have
the potential for abuse, addiction
and subsequently illegal use and
redistribution (diversion).

Opioids are not the only forms
of controlled substances. For ex-
ample, benzodiazepines and pow-
erful hypnotic medications are
controlled as well. Notably, the
Food and Drug Administration
has placed a black-box warning on
the co-administration of benzodi-