Table 1.

General Dos and Don’ts Regarding the Use of Opioid Therapy in Patients with Chronic Noncancer Pain

Consider opioids only after all other reasonable attempts at analgesia have failedForget to evaluate patients (ie, history and physical examination)
Recognize that a history of substance abuse, severe character pathology, and chaotic home environment are contraindicationsInitiate treatment without first establishing a diagnosis
Ensure that the primary responsibility for treatment is assumed by a single practitionerForget to obtain outside medical records or to talk with previous practitioners (any verification at all)
Obtain informed consent from the patient before initiating therapyPrescribe treatment without establishing specific goals (ie, reduction in pain, improvement in function)
Prescribe doses on an around-the-clock basisFail 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 patientFail to document the diagnosis, treatment plan, goals for treatment, continuing need for medication, and laboratory results
Emphasize gains in physical and social functionFail to understand what drug testing can and cannot tell you
Permit patients to transiently escalate dose on days of increased painDeviate 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 treatmentAccept 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 baselineAttempt 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