School of Medicine
Office of Medical Education:
Addiction Fellowships
Prescribing Controlled Drugs in Chronic Pain Patients
Using PEARLS to Avoid PITFALLS
Ted Parran MD
BACKGROUND PRINCIPLES:
•Be aware of projective identification!
If you have a “heart sink patient” (your heart sinks when you see their name on the schedule) and you are chronically
prescribing controlled drugs to this patient, then step back and look for one of these three often missed diagnosis:
1) borderline personality disorder (rare)
2) somatization disorder (un-common)
3) addictive disorder with pressuring of the Dr-Pt relation to pursue the Pt-controlled drug relationship
(quite common)
•Remain within your area of expertise.
Patietns with addictive disorders are quite unconsciously facile at engendering “mission creep” with doctors who are
prescribing them controlled drugs. This often results in the situation where physicians find them selves prescribing controlled
drugs very un-characteristically and very un-comfortably in a very small number of patient cases.
•Stay grounded in you role – “FIRST do no harm…and THEN comfort always and cure sometimes!
Remember, if a physician does harm while trying to relieve suffering, receives evidence of that harm, and still
continues to do so despite that knowledge – then the subsequent medical care has been found to not meet usual standards, and in
extreme situations to be outside of legitimate medical practice.
DECISIONS TO PRESCRIBE CHRONIC CONTROLLED DRUGS: “The 5 Questions”
Question #1: “Is there a clear diagnosis”
Prior to prescribing you must identify a clear diagnosis, and document it.
Question #2: “Have you Documented and adequate work-up?”
Prior to chronically prescribing controlled drugs be sure to document and adequate work-up. Copies of old records,
previous studies, consultations, a full H&P, assessment, and plan are necessary.
Question #3: “Is there impairment of function?”
The goals of acute pain management may well be “relieve pain, avoid side effects, while the patient heals”, and in
malignant pain situations may be relieve pain, avoid side effects while the patient passes away”. However the goal of chronic
pain management might be best described as “improve function and assist the patient to manage their pain.” Consequently a
functional assessment corroborated by one or two “significant others” prior to committing to prescribing controlled drugs is of
great importance.
Question #4:Has a non-controlled drug multi-modal pain management program failed?”
This should be obvious, but also should be documented in the chart.
Question #5: “Have contraindications to opioids been ruled out?”
The contraindications – relative and absolute – are pretty straignt forward…history of addiction to opioids ??absolute,
current addiction to opioids ?? absolute, current or past history of addictive disease but opioids never a drug of choice =
relative. WHY? - Prescribing chronic opioid analgesics on a relatively un-supervised outpatient basis to a patient who has a
current or past history documenting an inability to control the use of opioids is a clinical decision fraught with peril for the patient
and risk for the prescribing physician.
If the answer to EACH of these “5 Questions” is not “yes”, then avoid chronic opioid therapy in the patient!
10900 Euclid Avenue * Cleveland, Ohio 44106-4922 * (216) 368-6934 Fax: (216)368-0535
Email: tvp@po.cwru.edu
Web site: www.cme.cwru.edu
RULING OUT ADDICTION: CAGE, f-CAGE and toxicology testing
The CAGE questionnaire
Has the patient felt a need to CUT Down on their use of alcohol or other drugs?
Has the patient had comments made by friends or family the have ANNOYED, regarding the use of alcohol or other
drugs?
Has the patient felt bad, bashful or GUILTY about things said or done when on alcohol or other drugs?
Has the patient used alcohol or other drugs in the morning (EYEOPENERS) to treat shakes / withdrawal?
The f-CAGE
Ask the CAGE questions, about the patient’s use of the two significant others indicated above who corroborated the
functional assessment.
Toxicology testing
It is entirely appropriate to insist on one or two toxicology tests prior to committing to prescribing chronic controlled
drugs to a patient. These toxicology tests should document that prescribed drugs are present and that non-prescribed drugs or
illicit ones are not.
TIPS TO THE PRESCRIBING OF CHRONIC OPIOIDS IN CHRONIC PAIN
Use a Chronic Controlled Substance Agreement
These agreements are very useful for identifying for the staff, the physician, the patient and the patient family the
ground rules for prescribing. It should include informed consent regarding the risks and benefits of chronic opioids, and
agreement by the patient to:

only see one doctor

only use one pharmacy

follow through on all referrals

only take the medications as prescribed and never alter dose on own

shepherd the medications and never ask for an early refill

abstain from alcohol and other substance use

identify two “significant others” who can be contacted to corroborate the history

agree to periodic toxicology testing

Factor in Tolerance
IF the patient has been on controlled drugs prior to your prescribing, start with equi-analgesic doses of what ever you
will choose to prescribe.
Start low and go slow
After adjusting for tolerance, start with a low dose of opioid, and slowly increase it as functional capacity is assessed.
If prescribing methadone, never the dose upward more often than once every five to seven days due to the potential for prolonged
and progressive respiratory depression.
Use long acting opioid preparations
Long acting or long half-life opioids are often the most appropriate for treating chronic pain syndromes.
Use fixed dosing schedules and not prn dosing of these long acting opioids
Long acting opioids are perhaps optimal when used as a scheduled dose, on a day-in and day-out basis.
Avoid short acting opioids for “prn” or “breakthrough” use once chronic long acting opioids are initiated
In this instance, controlled drug prescribing in chronic pain syndrome perhaps should be very different than controlled
opioid prescribing in acute or malignant pain syndromes. The common practice of using prn opioids for breakthrough pain in
acute and malignant pain treatment should be avoided in chronic pain management, as it appears that this prescribing may be
integral to escalating tolerance. In addition short acting prn opioids are often highly sought by patients with addiction. Instead it
is suggested to use combinations of acetaminophen / NSAIDS / and tramadol products for treating prn breakthrough pain, and
have the patient track how many days / month the prn medications are needed. The goal is to adjust the chronic opioid dose so
that prn medications are necessary on less than 1/3 of the days of the month.
Avoid poly-pharmacy regarding controlled drugs
The chronic prescribing of several different opioids, with or without benzodiazepines and/or barbiturates and/or
scheduled stimulants is a prescribing pattern of concern. It runs great risk of attracting patients with addiction to the practice –
which is always a bad sign (see projective identification above).
10900 Euclid Avenue * Cleveland, Ohio 44106-4922 * (216) 368-6934 Fax: (216)368-0535
Email: tvp@po.cwru.edu
Web site: www.cme.cwru.edu
MONITORING STRATEGY WHEN PRESCRIBING CHRONIC OPIOIDS
Document functional improvement
A periodic (twice a year) Occupational Therapy consult can quantify functional improvement. Alternatively having the
office staff periodically (q 3-4 months) ask the patient and the patient’s two corroborators the following questions “what can you
do now, what could you do before starting on chronic opioids, and what would you be doing if you had no chronic pain?”
Documenting the response to these questions is an office based functional assessment.
Titrate opioid dose to maximum function AND low use of prn medications
Do pill counts of controlled AND non-controlled prescribed drugs
Perform a periodic toxicology screen
A routine urine screen every 3-6 months for drugs of abuse is usually sufficient regarding toxicology testing. It is
important to write-in on the lab requisition the name of any prescribed drug … since urine dip-stick technology can sometimes
miss certain prescribed drugs. A quantitative serum level is rarely needed, and probably should be used on a very rare basis
(annually) with patients who are on extra-ordinarily high opioid doses – to document that they are well above the “therapeutic”
range, and thus actually taking the extraordinary doses!
Avoid non-planned escalation
Non-planned escalation can be indicative of not taking tolerance into account when initiating chronic opioid therapy, or
more concerning a patient who is taking medication other than prescribed, or most concerning a patient who has addiction and is
chasing the euphoria of the opioid. The brain develops rapid chronic tolerance to the euphoria producing effect of opioids, while
developing slow partial (perhaps minimal) tolerance to the analgesic effects of an opioid analgesic. This tolerance re: analgesia
should be even less if prn short acting opioids are avoided. So a relentless escalation of dose on the part of the patient is quite
concerning.
Monitor for SCAMS by using the Controlled Substance Agreement and refusing early refills – NO MATTER WHAT
Scams are efforts to pressure the Dr-Pt relationship in order to pursue the Pt-controlled drug relationship! They usually
take the form of reasons for early refills, but can also include flattery, gifts, excessive boundary violations, etc. Typical scams
include losing the medicine / script, spilling it, washing it in the laundry, having it stolen, being eaten by various animals, losing
luggage, houses burning down, being shorted by the pharmacist, etc etc etc. The best way to deal with early refill requests is to :
1) refer back to the agreement
2) decline to fill it early but rather when it is due (“just say NO and mean it”)
3) educate the patient about withdrawal symptoms, and urge an ER visit and a page to you IF such symptoms emerge
4) reinforce that you do not want them sick, but you must know that they are safe
5) see the patient for a return visit and prescription when previously scheduled – not before
Patients with addictive disease tend to binge on their medications as they episodically lose control over their use (the defining
characteristic of addictions). When they lose control they run out early and have to resort to scams to replenish their supply. As
a consequence, early refill requests are frequently indications of out-of-control behavior. As such they cannot be re-enforced or
rewarded with early refills.
EMERGENCY CONTRAINDICATIONS TO CONTINUED PRESCRIBING: “the 5
Commandments!”
THOU SHALT NOT WRITE ANOTHER CONTROLLED PRESCRIPTION EVER if any of the following happen:
1) Altering or forging a prescription - felony (above all first do no harm!)
2) Accidental overdose – death (above all first do no harm!)
3) Reports of selling prescriptions - felony (above all first do no harm!)
4) Threatening behavior toward the physician or staff – out of control (above all first do no harm!)
5) Too many (?3 strikes?) attempted scams … despite not reinforcing them with refills – out of control (above all
first do no harm!)
How to stop prescribing opioids IF an emergency contraindication arises (ie you have evidence of doing harm)
1) Identify the contraindicated behavior.
2) State that further prescribing is inappropriate.
3) Educate about withdrawal symptoms and offer referral for detoxification.
4) Instruct to go to the E.R. if withdrawal.
5) Offer continued care with out controlled drug Rx in the future.
10900 Euclid Avenue * Cleveland, Ohio 44106-4922 * (216) 368-6934 Fax: (216)368-0535
Email: tvp@po.cwru.edu
Web site: www.cme.cwru.edu