5 Questions With ACP’s Dr Davoren Chick: SAFE Opioid Prescribing
Although opioids are commonly prescribed in the United States for chronic pain, they can often do more harm than good for some patients.
Approximately 21% to 29% of patients who are prescribed opioids for chronic pain misuse them, and 8% to 12% of patients develop an opioid use disorder, according to the National Institute on Drug Abuse.1
Furthermore, these highly addictive painkillers are responsible for more than 115 deaths due to overdose per day in the United States.1
Now more than ever, it is important for clinicians to exercise safe opioid prescribing practices to prevent drug misuse and abuse, said Davoren Chick, MD, FACP, Senior Vice President for Medical Education at the American College of Physicians (ACP).
Dr Chick discussed safe prescribing practices at the ACP Internal Medicine Meeting in New Orleans, Louisiana, where she directed “SAFE Opioid Prescribing: Strategies. Assessment. Fundamentals. Education.”
Consultant360 recently spoke with Dr Chick, who answered our questions about her presentation.
Consultant360: What does a "safe" opioid treatment regimen look like? And who qualifies for these regimens?
Davoren Chick: The term "SAFE" in ACP's course on "SAFE Opioid Prescribing" is an acronym for "Strategies. Assessment. Fundamentals. Education." No opioid prescription is without risk. Our course focuses on how to assess individualized risk, compare that risk with an individual's potential benefit, and offer opioid therapy only to patients for whom potential benefits outweigh risks.
C360: When should a provider prescribe extended-release vs long-acting opioids?
DC: In general, immediate-release opioids are preferred in the lowest effective doses as necessary. Use of specific medications, whether immediate-release (IR), extended-release (ER), or long-acting (LA), depends on the nature of the treated pain, the patient's individual comorbid conditions (such as kidney or liver disease), coprescribed medication interactions, ability to swallow, opioid tolerance, side effects, and so on.
There is no one right answer in selecting between ER and LA preparations, which is why providers are educated about a range of ER/LA options in our SAFE Opioid Prescribing Risk Evaluation and Mitigation Strategy (REMS)-compliant course.
C360: What is the best practice for starting, maintaining, and ending opioid therapy? How do you monitor adherence?
DC: Before starting opioids, each patient should be assessed for medical appropriateness, goals of therapy, and risk/benefit analysis. Each of these 3 pillars requires attention, and specific resources are available to support a thoughtful approach.
A well-documented initial plan supports future monitoring of progress toward goals, changes in individualized risks, and mitigation of those risks. We advise using the Centers for Disease Control and Prevention's checklists on prescribing,3 which guide each pillar. Adherence is monitored during regular visits in which treatment goals, side effects, and pharmacy drug monitoring program data should be reviewed. Urine drug screening frequency should be individualized.
Best practices for discontinuation of opioids are also dependent on the reasons for discontinuation; a taper off opioids is advised when treatment is not adequately contributing to goals of therapy. More rapid tapers are necessary in settings of higher risk.
C360: In your opinion, what is one possible solution to the current opioid epidemic? Who plays the biggest role?
DC: There is no one solution, nor is there one "who." The opioid epidemic requires a complete system approach, including nonpharmacologic and nonopioid pharmacologic supports for persons with pain, appropriate reimbursement for counseling and nonpharmacologic services, patient education, clinician education, and pharmaceutical standards.
ACP supports clinicians and their patients by providing clear, evidence-based, and actionable information about pain, nonpharmacologic pain management, nonopioid pharmacologic treatments, and risk mitigation when opioids are used as part of a comprehensive pain management program.
C360: What is the most common question you receive from the audience after presenting this course?
DC: Physicians manage many patients who have individual needs that do not easily fit into guideline care. Therefore, most clinicians ask questions related to active clinical conundrums, and they seek greater access to subspecialty pain medicine consultants.
1. Opioid overdose crisis. National Institute on Drug Abuse. Last revised March 2018. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis. Accessed on April 24, 2018.
2. Chick D. SAFE Opioid Prescribing: Strategies. Assessment. Fundamentals. Education. Presented at: American College of Physicians Internal Medicine Meeting; April 19-21, 2018; New Orleans, LA.
3. Checklist for prescribing opioids for chronic pain. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/pdf/PDO_Checklist-a.pdf. Accessed on April 24, 2018.