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OPIOID CRISIS
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the patient should follow when taking these medications. These in- J Med 2003;349:1943-53.
clude: not obtaining pain medication from another prescriber or in- 7. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P,
dividual, not using illicit substances, taking the medication as
prescribed, random monitoring, and being compliant with the rest Owens DK; Clinical Efficacy Assessment Subcommittee of the
of the treatment plan. Discontinuation of opioid therapy due to American College of Physicians; American College of Physicians;
non-compliance with the treatment plan should be addressed in the American Pain Society Low Back Pain Guidelines Panel. Diagno-
CSA. Recent evidence suggests that it may be prudent to restrict sis and treatment of low back pain: a joint clinical practice guide-
driving in patients who are prescribed opioids, and this may be placed line from the American College of Physicians and the American
in the CSA as well, but this data is controversial (13). Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91.
8. Burton K, et al. The Back Book, 2nd ed. The Stationary Office,
Once the patient has been placed on chronic opioid therapy, mon- UK, 2002 July.
itoring with random urine drug screens and pill counts is recom- 9. Manchikanti L, Helm S 2nd, Fellows B, Janata JW, Pampati V,
mended (12). Periodic review of the patient’s diagnosis, Grider JS, Boswell MV. Opioid epidemic in the United States.
appropriateness for therapy and patient compliance should be made. Pain Physician. 2012 Jul;15(3 Suppl):ES9-38.
Improvements in functional status and pain states should be noted, 10. Texas Medical Board Rules, Chapter 170, Authority of Physi-
and if the individual patient is not improving in both function and cians to Prescribe for the Treatment of Pain
pain, re-evaluation is warranted. In Texas, we have a robust Prescrip- 11. www.cdc.gov/drugoverdose/prescribing/guideline.html
tion Monitoring Database Program (PMP or PMDP) that should be 12. Owen GT, Burton AW, Schade CM, Passik S. Urine drug testing:
utilized periodically to ascertain if a patient is obtaining prescriptions current recommendations and best practices. Pain Physician.
from other providers (14). If necessary, psychological evaluations 2012 Jul;15(3 Suppl):ES119-33.
should be provided either at the evaluation stage, during the moni- 13. Nagpal A, Xu R, Pangarkar S, Dworkin I, Singh JR. Driving
toring process or both. Under the Influence of Opioids. PM R. 2016 Jul;8(7):698-705.
14. https://texas.pmpaware.net/
CONCLUSION
A stigma has been attached to chronic pain patients for a long ABOUT THE AUTHORS:
Max Eckmann, MD, is an associate professor and medical
time. There is now a stigma on providers, as well. It is fair to say that
part of the preconceptions that our society has about prescribers of director of pain medicine in the Department of Anesthesiology
opioids for chronic pain is based upon poor judgment by the at The University of Texas Health Science Center at San An-
provider regarding the evaluation and monitoring process of patients tonio, now doing business as UT Health San Antonio. Dr.
who are otherwise being treated appropriately with these addictive Eckmann is board-certified in both pain medicine and anesthesiology by the
medications. Safe opioid prescribing involves selecting the right pa- American Board of Anesthesiology. As a fellowship program director, Board
tients and monitoring them for signs of abuse, misuse, addiction and Member of the Texas Pain Society and an active planning participant in na-
diversion over time. tional organizations such as the American Society of Anesthesiologists and
American Society of Regional Anesthesia and Pain Medicine, Dr. Eckmann
REFERENCES has an up-to-date perspective on medical and legal trends in his specialties and
1. Holmes A, Williamson O, Hogg M, Arnold C, O'Donnell ML. how those interact with other medical and surgical specialties.
Determinants of chronic pain 3 years after moderate or serious Ameet Nagpal, MD, MS, MEd, is an assistant professor
injury. Pain Med. 2013 Mar;14(3):336-44. and medical director of UT Health San Antonio Pain Con-
2. Gaskin DJ, Richard P. The economic costs of pain in the United sultants. He is board-certified in pain medicine and physical med-
States. J Pain. 2012 Aug;13(8):715-24. icine and rehabilitation by the American Board of Physical
3. Krames ES. The Role of the Dorsal Root Ganglion in the De- Medicine and Rehabilitation. Dr. Nagpal is the associate program director of
velopment of Neuropathic Pain. Pain Med. 2014 Mar 18. the UT Health San Antonio Pain Medicine Fellowship. He is highly active
4. Agency for Health Care Policy and Research (AHCPR), Clinical with the Spine Intervention Society as a speaker and volunteer for their Evidence
Practice Guidelines, Acute Pain Management, Feb 1992-Dec Analysis Committee and Education Division, and with the American Associ-
1994. ation of Physical Medicine & Rehabilitation as a speaker and volunteer on
5. Chou R, et. al.; American Pain Society-American Academy of their Self-Assessment Committee. He also spends a significant portion of his
Pain Medicine Opioids Guidelines Panel. J Pain. 2009 administrative time working with undergraduate medical students as a course
Feb;10(2):113-30. coordinator, discipline coordinator and Curriculum Committee member.
6. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl
22 San Antonio Medicine • October 2017