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