Pain Management vs. Treating the Underlying Causes of Pain

According to the defense expert in the following case, patients who can’t or won’t engage in alternative treatments for their pain should not be prescribed pain medications as a matter of course. Consider how the overdose in the following case could have been prevented if the internist had followed the CDC opioid prescribing guidelines.

Allegation

The internist negligently prescribed excessive narcotic medications without proper checks and balances following the patient’s detox treatment.

Case File

In January 2010, the patient’s internist was refilling her prescription for 100 tablets of 10 mg oxycodone and 325 mg acetaminophen, 1 tablet every 4 hours as needed for diabetic peripheral neuropathy every two weeks. (MME/day = 90.) By May 2010, he had increased her prescription to 1 to 2 tablets of 10 mg oxycodone and 325 mg acetaminophen every four hours. (MME/day = 180.) Starting in August 2010, the internist started to worry about the high MME and suspected addiction, but continued to prescribe the same amount of 10 mg oxycodone and 325 mg acetaminophen. By October 2010, the internist was refilling the patient’s prescription every week. In an attempt to reduce the patient’s need for 10 mg oxycodone and 325 mg acetaminophen, he started prescribing diazepam and pregabalin. This continued until the patient started opioid addiction treatment in March 2011.

Following treatment, the patient was opioid free until June 2012, when she had surgery. Her surgeon prescribed hydromorphone, 4 mg every 4 hours; 75 mg fentanyl patch, 60 mg codeine, and 300 mg acetaminophen 4 times per day for post-surgical pain relief. (MME/day = 330.) Thereafter, the internist refilled the prescriptions. In September 2012, although the internist advised re-entering opioid addiction treatment, he resumed prescribing 10 mg oxycodone and 325 mg acetaminophen as before, discontinued 60 mg codeine and 300 mg acetaminophen, and added diazepam. (MME/day = 366.) Refills for hydromorphone, fentanyl patch, 10 mg oxycodone and 325 mg acetaminophen and diazepam continued until the patient accidentally overdosed in January 2013. Her cause of death was determined to be mixed prescription intoxication. Toxicology reports revealed the presence of morphine, codeine, oxycodone and diazepam in her system.

The patient’s husband filed a wrongful death lawsuit alleging the internist prescribed excessive narcotic medications without proper checks and balances to ensure that abuse was not occurring, and that he negligently prescribed narcotics following detox and caused the plaintiff’s wife to become addicted again.

Discussion

Experts were critical of the internist for negligently acting as a pain management specialist and failing to treat the underlying causes of the patient’s pain. For example, there was no evidence in the patient’s record that the internist educated her about the relationship between poorly controlled diabetes and peripheral neuropathy, or that he worked with the patient to improve her compliance. Furthermore, experts believed it was below the standard of care to prescribe pain medications with no plan, screening, contract or long-term goals. Significantly, the patient had managed without opioid pain medications for over a year following opioid addiction treatment; but, instead of encouraging the patient to discontinue the opioids she had received for acute pain following surgery, the internist refilled and eventually increased them. Experts believed this was inconsistent with the standard of care.

Addressing Overdose at the Source

The CDC guidelines are perhaps most useful in providing strategies to prevent opioid dependence and addiction, and thereby reduce overdose deaths. For example, one way to decrease overdose deaths is to stop initiating opioid treatment for pain associated with nonspecific musculoskeletal disorders (e.g., back pain, headaches, fibromyalgia).¹

Another strategy for decreasing opioid overdose deaths is to keep acute pain patients from becoming dependent on pain medications. For patients being treated for acute pain that is not surgical or traumatic, the guidelines urge physicians to prescribe the lowest effective dose necessary for three days or less, after which the likelihood of physical dependence significantly increases without any added benefit. Limitation of pain medications for acute pain can not only expose fewer patients to withdrawal symptoms, it can decrease the number of pills available for diversion.¹

Risk Reduction Strategies

Consider the following recommendations, which are primarily based on the CDC guidelines:^1,2,3,4,5

• Create policies and procedures for prescribing opioids for chronic pain management.
  • Educate patients about your policies and procedures.
  • Clarify expectations for your responsibilities and the patient’s, including:
    • How opioids will be prescribed (e.g., no early refills) and monitored (e.g., set appointments, urine tests and PDMP surveillance).
    • What will trigger discontinuation or tapering (e.g., if treatment goals are not met).
  • Prioritize alternatives to opioid therapy.
    • When appropriate, prior to considering opioid pain medications, prescribe a trial of non-opioid medications and non-pharmaceutical therapies that have been shown to decrease chronic pain, for example, physical therapy, counseling, psychotherapy, cognitive-behavioral therapy (CBT), sleep hygiene improvement, graded exercise, mindfulness-based stress reduction techniques, spinal manipulations, meditation and yoga.
  • Explicitly and realistically educate patients about the risks, benefits and alternatives of opioid therapy.
    • Explain the lack of evidence to support long-term opioid therapy for chronic non-cancer pain. (The CDC refers to this lack of evidence as support for various aspects of the new guidelines.¹)
    • Ensure patients understand that complete, long-term pain relief is unlikely.
    • Emphasize improvement in function as a primary goal.
    • Ensure patients understand the risks of opioids, including addiction risk and increase in overdose risk when opioids are taken with benzodiazepines, other sedatives, alcohol, street drugs or other opioids.
    • Ensure patients understand that over time, pain and function improvements can diminish and risks can increase.
  • Involve patients in decision making.
    • Discover what the patient’s preferences and values are and integrate those into pain management decisions.
      • Be prepared with counter arguments for patients who want to limit treatment to opioid pain medication.
    • Screen for prior/current substance abuse and mental health disorders (see our closed claim case study, “Increased Overdose Risk When Combining Opioids With Other Medications,” for additional risk reduction strategies).
    • Use a pain medication agreement whenever choosing opioid therapy for chronic pain management.
    • Treat the cause of the patient’s pain.
      • Work with the patient to reduce pain triggers.
    • Establish and track progress toward treatment goals.
      • Establish functional goals (e.g., walking the dog, gardening, returning to part-time work).
      • Use guideline-based screening tools.
      • Assess pain and function at every visit to create a record of opioid treatment efficacy.
    • Monitor patient compliance in regular follow-up assessments.
      • Evaluate benefits/harms within one to four weeks of initiation or of dose escalation.
        • Follow ups should be closer to one week from ER/LA initiation or dosage increase or when total daily opioid dosage is ≥50 MME/day.
        • Follow up should be within three days when starting or increasing methadone.
      • If there is no clinically meaningful improvement (≥30%) in pain and function as compared to the start of treatment or in response to a dose change, or if adverse effects are significant, taper and discontinue opioids and use other approaches to pain management.
      • Consult with pain management specialists when appropriate.
        • During the referral process, discuss any opioid use disorder concerns.
        • Inform the consulting pain management specialists when patients continue to seek pain medications from you after being referred.
      • Appropriately document all phases of pain management and the reasoning behind dosage decisions.

References

1. Deborah Dowell, et. al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports 2022;71(No. RR-3):1–95. November 4, 2022. DOI: 10.15585/mmwr.rr7103a1

2. Franklin GM. Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology. Neurology 2014;83:1277-1284.

3. Manchikanti L, et al. American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain. Pain Physician 2012;15:S1-S66.

4. Smith PC, et al. A Single-Question Screening Test for Drug Use in Primary Care. Arch Intern Med. 2010;170(13):1155-1160.

5. Buppert C. “New Standard of Care for Prescribing Opioids.” 16 Apr 2015. Medscape.