General Dos and Don’ts Regarding the Use of Opioid Therapy in Patients with Chronic Noncancer Pain
| Do | Don’t |
|---|---|
| Consider opioids only after all other reasonable attempts at analgesia have failed | Forget to evaluate patients (ie, history and physical examination) |
| Recognize that a history of substance abuse, severe character pathology, and chaotic home environment are contraindications | Initiate treatment without first establishing a diagnosis |
| Ensure that the primary responsibility for treatment is assumed by a single practitioner | Forget to obtain outside medical records or to talk with previous practitioners (any verification at all) |
| Obtain informed consent from the patient before initiating therapy | Prescribe treatment without establishing specific goals (ie, reduction in pain, improvement in function) |
| Prescribe doses on an around-the-clock basis | Fail to screen for addictive potential and monitor patient through treatment |
| Reassess if failure to achieve at least partial analgesia at relatively low initial doses in the nontolerant patient | Fail to document the diagnosis, treatment plan, goals for treatment, continuing need for medication, and laboratory results |
| Emphasize gains in physical and social function | Fail to understand what drug testing can and cannot tell you |
| Permit patients to transiently escalate dose on days of increased pain | Deviate from the ‘contract’ (ie, misbehavior is never addressed either verbally or written) |
| See patients and prescribe drugs at least monthly, at least in the initial phases of treatment | Accept blindly whatever is said by the patient |
| Manage exacerbations of pain in the hospital, where dose escalation can be observed and the dose returned to baseline | Attempt to bully law enforcement or regulatory agents, or assume an arrogant ‘I-know-best’ attitude when confronted by them |
| Assess patients for evidence of drug hoarding, acquisition of drugs, uncontrolled dose escalation, or other aberrant behaviors | |
| Incorporate comfort, side effects, functional status, and existence of aberrant drug-related behaviors into pain assessment at each visit | |
| Consider use of self-reporting instruments, an example of which is shown in Table 2 | |
| Remember that documentation is essential and should address all elements of the visit assessment |
Adapted with permission from Portenoy28 and Gallagher.18