Federation of State Medical Boards updates guidelines for chronic use of opioids
The guidelines address ongoing monitoring, treatment agreements, and state prescription drug monitoring programs, among other areas.
The Federation of State Medical Boards (FSMB) recently updated its guidelines on chronic use of opioid analgesics.
The guidelines focus on safe and evidence-based prescribing of opioids and treatment of chronic, noncancer pain and are not intended to create any specific standard of care, the guideline authors wrote.
The guidelines apply most directly to the treatment of chronic pain that lasts more than three months, or past the time of normal tissue healing. They do not encourage prescribing opioids over other pharmacological and nonpharmacological means of treatment, nor are they intended for the treatment of acute pain, perioperative pain management, cancer-related pain, palliative care, or end-of-life care, the authors noted.
The guidelines cover the following areas:
Patient assessments, evaluations, and ongoing monitoring. The medical record should document the presence of one or more recognized medical indications and absence of psychosocial contraindications for prescribing an opioid and should reflect an appropriately detailed patient evaluation. The initial assessment and evaluation should include a systems review and relevant physical examination, objective markers of disease or diagnostic markers as indicated, and a functional assessment.
Treatment agreements. Written informed consent and treatment agreements are recommended for long-term, chronic opioid therapy. They should outline the clinician's and patient's joint responsibilities, should discuss how and when the prescription drug monitoring program (PDMP) will be reviewed as part of the patient's care, and should include treatment goals, the patient's responsibility for safe medication use, and information about secure storage and safe disposal.
State PDMPs. It is strongly recommended that physicians consult the PDMP in their state before starting opioid therapy and at appropriate intervals thereafter to determine whether patients are receiving prescriptions from other clinicians.
Alternatives to and discontinuation of opioid therapy. Nonopioid and nonpharmacologic treatments should be considered before starting opioid therapy for chronic or acute pain lasting beyond the expected duration. “Discontinuing or tapering of opioid therapy may be required for many reasons, and ideally, clinicians will have an end strategy at the outset of treatment,” the authors wrote.
Concurrent use of benzodiazepines. Increased risk for adverse events, including death, is greatly increased with concurrent use of benzodiazepines and opioids, which recently received a “black box” warning from the FDA. Clinicians should therefore avoid such concurrent prescriptions whenever possible, the guidelines recommended.
Naloxone and methadone. Coprescription of naloxone should be considered for home use for all patients with opioid prescriptions in case of accidental or intentional overdose by patients or household contacts. Overdose risk is highest in patients with a history of substance use disorder, a history of overdose, clinical depression, concurrent use of other central nervous system depressants, or other markers of increased risk (e.g., behaviors, family history, PDMP, and risk assessment results). Before clinicians prescribe methadone for its analgesic effect, it is strongly recommended that they receive specific training and/or experience, the authors wrote.