What is the Role of the Personal Injury Lawyer in Baltimore Md Involving Pain Management

What is the role of the personal injury lawyer in Baltimore Md  involving pain management in either a workers’ compensation or personal injury case?

More often than desirable,a personal injury lawyer in Baltimore Md  representing a client in a workers’ compensation claim or a personal injury claim is thrust into the middle of a dispute between client, doctor, government, and insurance company regarding the issue of pain management.

Typical situation: client of a personal injury lawyer in Baltimore Md is involved in serious, either work-related injury or personal injury claim, that either requires surgery or significant medical treatment that is unsuccessful. After the unsuccessful treatment, client continues to be in significant pain. As a result of the initial serious injury and sometimes as a result of unsuccessful invasive treatment the client has received, the client needs pain management. Treatment provided to date to control pain have been unsuccessful and the treating doctor either initiates pain management in his office or refers the client to a pain management specialist. Client of the personal injury lawyer in Baltimore Md is initially started on low levels of pain management medications. Client either builds up a tolerance to the medication or purposely abuses the medication and the doctor needs to increase the dosage of the medication in order to control the pain the client complains about. Ultimately, client becomes dependent upon or addicted to the medication, creating a new and more serious deadly medical problem. The personal injury lawyer in Baltimore Md  is presented with the following conundrum.

Clients of personal injury lawyer in Baltimore Md  typically feel that they cannot live without the medication. Any other treatment they have had has been unsuccessful and the narcotics provide them the only relief from pain they have had throughout the whole process. Clients want to be in charge of their own health decisions and do not want lawyers, insurance companies or judges making medical decisions for them. Clients often note that they are the ones having to live with the pain and therefore they are the ones who can best decide what is in their best interests. Clients always deny that they will get addicted or that they are in fact addicted to drugs. They feel that the only thing that’s helping them survive in life is the pain medication that they’re taking. Clients feel that if they were taken off the medication that the pain would be so extreme that they could no longer tolerate it.

At that point, the cost for the medication has become so prohibitive that the insurance company wants to wean the client off the medication and the client of the personal injury lawyer in Baltimore Md does not want that. Insurance companies ultimately are in the business of making money. Insurance may initially be willing to pay for pain medication in the acute stage. But as the cost for pain medication continues to escalate with no end in sight, the insurance company will usually draw a line. The insurance company demands for the doctor to detox the patient. Even if all parties except the client agree that detox is the appropriate treatment, the issue becomes what is the best way to detox the patient without affecting their health. Some insurance companies ask the doctor to slowly wean the patient despite the fact that the doctor may not agree with this approach. Some insurance companies take the position that if the doctor refuses to decrease the pain medication in the manner and time table they feel is appropriate, then the insurance company refuses to authorize any treatment or medication effective immediately endangering the health of the patient. Other insurance companies especially in a worker’s compensation setting, set the case for hearing in order to have the Worker’s Compensation Commission order the doctor to wean the patient from the pain medication.

Doctors, the professional best trained to deal with this issue, often drop the ball. Doctors, especially pain management doctors, owe an ethical obligation to their patient, to do no harm and in addition obviously provide valuable treatment to them including the alleviation of their pain. Doctors want to heal their patients, but are not miracle workers. Occasionally, their efforts to treat the patient are not as successful as they had hoped and the last resort is to manage the pain. Patients given the choice between expensive, invasive medical procedures and pills, often choose the pills. Patients who do not want to be in pain will ask for pain medications. Even after you explain the dangers of opioids to a patient, a significant number, still decide that nothing bad will happen to them. Doctors can offer the patient’s a multitude of choices with regard to pain management including surgery, physical therapy, injections, psychiatric treatment, biofeedback, and anti-inflammatory medication. However, once these have not worked, and the patient is still in pain, ultimately the doctor is left with opioid medications. Patients may be offered opioids in the initial stages of an injury called the acute stage at which time all doctors seem to agree opioids are likely appropriate. However, once the patient starts taking the opioids, and realizes that the other treatment that’s been provided hasn’t helped, the patient seems to be convinced that the opioid is the only viable method to treat their pain. It is much easier for a doctor to say yes to an opioid prescription than to spend 20 minutes explaining why it would not be appropriate in having an unhappy patient who would go to on to the next doctor. Prevention, assessment, and treatment of chronic pain are challenges for health providers and systems. Pain might go unrecognized, and patients, particularly members of racial and ethnic minority groups, women, the elderly, persons with cognitive impairment, and those with cancer and at the end of life, can be at risk for inadequate pain treatment.  Patients can experience persistent pain that is not well controlled. There are clinical, psychological, and social consequences associated with chronic pain including limitations in complex activities, lost work productivity, reduced quality of life, and stigma, emphasizing the importance of appropriate and compassionate patient care. Patients should receive appropriate pain treatment based on a careful consideration of the benefits and risks of treatment options.

Judges, juries and workers’ compensation commissioners are lawyers by training. When the parties cannot agree, Judges, juries and workers’ compensation commissioners are called upon to make medical decisions regarding medical issues for which they have no training. Courts are aware of the epidemic overuse of opioids and the deleterious effect it has had on society. Judges, juries and workers’ compensation commissioners, read every day in the paper about overdoses and deaths due to opioids. Judges, juries and workers’ compensation commissioners do not want to be responsible for participating in the destruction of another human being. In addition, Judges, juries and workers’ compensation commissioners do not want to help feed an addiction. Because laymen such as Judges, juries and workers’ compensation commissioners have no medical training, there is a tendency to lump all of these cases together and assume that narcotics are never appropriate and therefore everyone should be weaned.

The personal injury lawyer in Baltimore Md  representing the injured parties are in the middle because they are told by their clients that they want to have the pain management. It is the job of a personal injury lawyer in Baltimore Md   to zealously represent their client. Alternatively, an experienced personal injury lawyer in Baltimore Md  has repeatedly represented clients who have insisted that they cannot live without the pain medication and have become addicted to the pain medication. Experienced personal injury lawyer in Baltimore Md  observe repeat patterns where opioid pain management increase dosage without any increase in the quality of life for the client. A personal injury lawyer in Baltimore md  often wonders how do I know which patient is really in pain and needs the pain medication verses the client who is drug-seeking and doesn’t need the pain medication at all. These decisions seem more appropriate for the medical field, however more often than not are inappropriately dealt with by the doctors, shifting those issues to lawyers, judges, juries and workers’ compensation commissioners. If the personal injury lawyer in Baltimore Md  does not support the client’s desire for the drugs, he may risk losing client who feels the lawyer is not listening to their wishes, is not representing client zealously or that the lawyer is on the side of the insurance company. No matter what you tell the client at this point regarding the dangers of narcotics, they are likely to ignore your advice because they are now dependent on these drugs.

What is the personal injury lawyer in Baltimore Md   to do in this situation?

Take a proactive approach-

The simple answer is the personal injury lawyer in Baltimore Md  needs to take a proactive approach in a case where this situation is likely to arise. Hopefully by providing the client with useful information up front the whole situation can be avoided. It would be better if the doctors would deal with this situation, unfortunately all too often they do not. In general, try to have your clients stay away from narcotics altogether except in the first week or the acute stage of the injury. Studies seem to suggest the adverse effects from narcotics abuse far outweigh the benefits from the pain management provided by narcotics. Note while we lawyers are not doctors, we have been around long enough to see the negative consequences to our clients and their cases as a result of narcotics abuse.

Initial discussion with client by the personal injury lawyer in Baltimore Md  –

Clients will either complain that the doctor refuses to prescribe pain medication or the pain medication being prescribed is not strong enough. A frank discussion with the client regarding the dangers of narcotic medication is a good starting point. Later in this article, I will present some of the medical research in this area which will provide you with the necessary information you can relay to your client in order to reinforce hopefully what the doctor has already told them. Often clients who are questioning the doctors’ treatment recommendation regarding narcotics are interested in drug seeking only.

Assess which clients are likely to abuse

A personal injury lawyer in Baltimore Md needs to review medical reports-. A quick review of their medical history will usually confirm your suspicions. Review of their medical records will often reveal interesting psychiatric history or prior injuries where narcotics were prescribed and the need for client to be detoxed in the past. Look at client family history for addiction or psychiatric problems in the medical history.

Review judicial case search- A criminal back-round check as well as a traffic record check will often uncover prior involvement with the law involving drugs, thefts or driving while intoxicated.

A personal injury lawyer in Baltimore Md  needs to stay away from certain medical practices

Do not refer a client to a primary care doctor who you know will prescribe opioids. Clients are often referred by other providers to pain management doctors. Often clients look to the lawyer for recommendations on which doctor to use. Once you have been involved in the worker’s compensation arena or the personal Injury arena for a period of time an experienced lawyer will get to know the doctors with the good as well as bad reputation. Simply making the client happy by remaining silent when the client is referred to a medical practice that has a reputation for being liberal in prescribing narcotic medication is doing the client a disservice. In addition, in the long run, once a client has started down the narcotics road, a good amount of the lawyers’ time will be spent, arguing with the insurance company regarding authorization for follow up treatment with the pain doctor, filling prescriptions and independent medical evaluations. Frequently hearings are necessary to resolve narcotic issues. The better practice would be to steer clients to primary care or pain management doctors who deal with pain management in a variety of ways and not just by medicating the client.

Once your client is in pain management

If your client becomes involved in pain management that includes narcotics, review the medical reports regularly. Are the narcotics short term or are they being prescribed long term with no end in sight. Does the Doctor seem to be gradually increasing the dose even though the client seems to have the same complaints no matter what the dosage? If so, this may be an indication, that narcotics will not provide the answer the client is looking for. Is the doctor periodically doing a drug screen? If not get him to do one. If so, what does it show. If the testing does not show the narcotics prescribed, then your client may be diverting the drugs to a family member or friend or, more likely, they are selling the drug. If the drug screen shows other narcotics not prescribed or shows use of marijuana or alcohol this may indicate that your client is likely the type who will get addicted and probably should be weaned.

What’s a lawyer to say?

As personal injury lawyer in Baltimore Md , our gut tells us that narcotic use is not good for the client. I’m sure you have asked yourself, how do I know if my client is in pain and whether narcotics are appropriate? We rarely have the time to investigate the truth about opioids and the alternatives. Start with this basic premise and your decision on what your role should be will be obvious.

Facts regarding opioids abuse.

The rest of this article is all based upon information either directly copied or substantially copied but rearranged snippets from the CDC Guideline for Prescribing Opioids for Chronic Pain. Narcotics prescribed by a doctor may in fact be a bigger problem than illegal drug abuse. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. While benefits for pain relief, function, and quality of life with long-term opioid use for chronic pain are uncertain, risks associated with long-term opioid use are clearer and significant. Based on the clinical evidence review, long-term opioid use for chronic pain is associated with serious risks including increased risk for opioid use disorder, overdose, myocardial infarction, and motor vehicle injury (KQ2). At a population level, more than 165,000 persons in the United States have died from opioid pain-medication-related overdoses since 1999. Opioids are commonly prescribed for pain. An estimated 20% of patients presenting to physician offices with noncancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription. In 2012, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills. Opioid prescriptions per capita increased 7.3% from 2007 to 2012.

Chronic pain has been variably defined but is defined within this guideline as pain that typically lasts >3 months or past the time of normal tissue healing. Chronic pain can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or an unknown cause. Estimates of the prevalence of chronic pain vary, but it is clear that the number of persons experiencing chronic pain in the United States is substantial. The 1999–2002 National Health and Nutrition Examination Survey estimated that 14.6% of adults have current widespread or localized pain lasting at least 3 months. Based on a survey conducted during 2001–2003, the overall prevalence of common, predominantly musculoskeletal pain conditions (e.g., arthritis, rheumatism, chronic back or neck problems, and frequent severe headaches) was estimated at 43% among adults in the United States,

Opioid pain medication use presents serious risks, including overdose and opioid use disorder. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. In the past decade, while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly. Sales of opioid pain medication have increased in parallel with opioid-related overdose deaths). For example, a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain and followed for up to 13 years revealed that one in 550 patients died from opioid-related overdose at a median of 2.6 years from their first opioid prescription, and one in 32 patients who escalated to opioid dosages over200 morphine milligram equivalents (MME) died from opioid-related overdose.

The CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function, and reduce the number of persons who develop opioid use disorder, overdose, or experience other adverse events related to these drugs. This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use.

What are the negative consequences of opiates?

Serious adverse effects of opioids, including potentially fatal respiratory depression and development of a potentially serious lifelong opioid use disorder that can cause distress and inability to fulfill major role obligations.

Additional common effects of opioids, are constipation, dry mouth, nausea, vomiting, drowsiness, confusion, tolerance, physical dependence, and withdrawal symptoms when stopping opioids. Opioids affect ability to safely operate a vehicle, particularly when opioids are initiated, when dosages are increased, or when other central nervous system depressants, such as benzodiazepines or alcohol, are used concurrently. Opioids can result in opioid use disorder, respiratory depression, death at higher dosages, respiratory depression when opioids are taken with benzodiazepines, other sedatives, alcohol, illicit drugs such as heroin, or other opioids. Other risks include household members and other individuals if opioids are intentionally or unintentionally shared with others for whom they are not prescribed, including the possibility that others might experience overdose at the same or at lower dosage than prescribed for the patient, and that young children are susceptible to unintentional ingestion.

Effects of Opioid Therapy for Acute Pain on Long-Term Use

Two fair-quality retrospective cohort studies found opioid therapy prescribed for acute pain associated with greater likelihood of long-term use. One study evaluated opioid-naïve patients who had undergone low-risk surgery, such as cataract surgery and varicose vein stripping (94). Use of opioids within 7 days of surgery was associated with increased risk for use at 1 year. The other study found that among patients with a workers’ compensation claim for acute low back pain, compared to patients who did not receive opioids early after injury (defined as use within 15 days following onset of pain), patients who did receive early opioids had an increased likelihood of receiving five or more opioid prescriptions 30–730 days following onset that increased with greater early exposure. Versus no early opioid use, the adjusted OR was 2.08 (95% CI = 1.55–2.78) for 1-140 MME/day and increased to 6.14 (95% confidence interval [CI] = 4.92–7.66) for ≥450 MME/day (95).

Do opioids help in the long run?

No evidence shows a long-term benefit of opioids in pain and function versus no opioids for chronic pain with outcomes examined at least 1 year later. Extensive evidence shows the possible harms of opioids (including opioid use disorder, overdose, and motor vehicle injury). Extensive evidence suggests some benefits of nonpharmacologic and nonopioid pharmacologic treatments compared with long-term opioid therapy, with less harm.

Alternative treatments

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

Patients with pain should receive treatment that provides the greatest benefits relative to risks. The contextual evidence review found that many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, psychological therapies, and certain interventional procedures can ameliorate chronic pain. There is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip or knee osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2–6 months. Previous guidelines have strongly recommended aerobic, aquatic, and/or resistance exercises for patients with osteoarthritis of the knee or hip. Exercise therapy also can help reduce pain and improve function in low back pain and can improve global well-being and physical function in fibromyalgia. Multimodal therapies and multidisciplinary biopsychosocial rehabilitation-combining approaches (e.g., psychological therapies with exercise) can reduce long-term pain and disability compared with usual care and compared with physical treatments (e.g., exercise) alone. Multimodal therapies are not always available or reimbursed by insurance and can be time-consuming and costly for patients. Interventional approaches such as arthrocentesis and intra-articular glucocorticoid injection for pain associated with rheumatoid arthritis or osteoarthritis and sub acromial corticosteroid injection for rotator cuff disease can provide short-term improvement in pain and function. Evidence is insufficient to determine the extent to which repeated glucocorticoid injection increases potential risks such as articular cartilage changes (in osteoarthritis) and sepsis. Serious adverse events are rare but have been reported with epidural injection.

Several nonopioid pharmacologic therapies (including acetaminophen, NSAIDs, and selected antidepressants and anticonvulsants) are effective for chronic pain. In particular, acetaminophen and NSAIDs can be useful for arthritis and low back pain. Selected anticonvulsants such as pregabalin and gabapentin can improve pain in diabetic neuropathy and post-herpetic neuralgia (contextual evidence review). Pregabalin, gabapentin, and carbamazepine are FDA-approved for treatment of certain neuropathic pain conditions, and pregabalin is FDA approved for fibromyalgia management. In patients with or without depression, tricyclic antidepressants and SNRIs provide effective analgesia for neuropathic pain conditions including diabetic neuropathy and post-herpetic neuralgia, often at lower dosages and with a shorter time to onset of effect than for treatment of depression (see contextual evidence review). Tricyclics and SNRIs can also relieve fibromyalgia symptoms. The SNRI duloxetine is FDA-approved for the treatment of diabetic neuropathy and fibromyalgia. Because patients with chronic pain often suffer from concurrent depression, and depression can exacerbate physical symptoms including pain, patients with co-occurring pain and depression are especially likely to benefit from antidepressant medication. Nonopioid pharmacologic therapies are not generally associated with substance use disorder, and the numbers of fatal overdoses associated with nonopioid medications are a fraction of those associated with opioid medications (contextual evidence review). For example, acetaminophen, NSAIDs, and opioid pain medication were involved in 881, 228, and 16,651 pharmaceutical overdose deaths in the United States in 2010. However, nonopioid pharmacologic therapies are associated with certain risks, particularly in older patients, pregnant patients, and patients with certain co-morbidities such as cardiovascular, renal, gastrointestinal, and liver disease (see contextual evidence review). For example, acetaminophen can be hepatotoxic at dosages of > 3-4 grams/day and at lower dosages in patients with chronic alcohol use or liver disease. NSAID use has been associated with gastritis, peptic ulcer disease, cardiovascular events, and fluid retention, and most NSAIDs (choline magnesium trilisate and selective COX-2 inhibitors are exceptions) interfere with platelet Although opioids can reduce pain during short-term use, the clinical evidence review found insufficient evidence to determine whether pain relief is sustained and whether function or quality of life improves with long-term opioid therapy (KQ1).

For many patients, aspects of these approaches can be used even when there is limited access to specialty care. For example, previous guidelines have strongly recommended aerobic, aquatic, and/or resistance exercises for patients with osteoarthritis of the knee or hip and maintenance of activity for patients with low back pain. A randomized trial found no difference in reduced chronic low back pain intensity, frequency or disability between patients assigned to relatively low-cost group aerobics and individual physiotherapy or muscle reconditioning sessions. Low-cost options to integrate exercise include brisk walking in public spaces or use of public recreation facilities for group exercise. CBT addresses psychosocial contributors to pain and improves function. Primary care clinicians can integrate elements of a cognitive behavioral approach into their practice by encouraging patients to take an active role in the care plan, by supporting patients in engaging in beneficial but potentially anxiety-provoking activities, such as exercise, or by providing education in relaxation techniques and coping strategies. In many locations, there are free or low-cost patient support, self-help, and educational community-based programs that can provide stress reduction and other mental health benefits. Patients with more entrenched anxiety or fear related to pain, or other significant psychological distress, can be referred for formal therapy with a mental health specialist (e.g., psychologist, psychiatrist, clinical social worker). Multimodal therapies should be considered for patients not responding to single-modality therapy, and combinations should be tailored depending on patient needs, cost, and convenience.

For complex pain syndromes, pain specialty consultation can be considered to assist with diagnosis as well as management. Diagnosis can help identify disease-specific interventions to reverse or ameliorate pain; for example, improving glucose control to prevent progression of diabetic neuropathy; immune-modulating agents for rheumatoid arthritis; physical or occupational therapy to address posture, muscle weakness, or repetitive occupational motions that contribute to musculoskeletal pain; or surgical intervention to relieve mechanical/compressive pain. The underlying mechanism for most pain syndromes can be categorized as neuropathic (e.g., diabetic neuropathy, post therapeutic neuralgia, fibromyalgia), or nociceptive (e.g., osteoarthritis, muscular back pain). The diagnosis and pathophysiologic mechanism of pain have implications for symptomatic pain treatment with medication. For example, evidence is limited or insufficient for improved pain or function with long-term use of opioids for several chronic pain conditions for which opioids are commonly prescribed, such as low back pain, headache, and fibromyalgia. Although NSAIDs can be used for exacerbations of nociceptive pain, other medications (e.g., tricyclics, selected anticonvulsants, or transdermal lidocaine) generally are recommended for neuropathic pain. In addition, improvement of neuropathic pain can begin weeks or longer after symptomatic treatment is initiated.

When are opioids appropriate?

Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

The clinical evidence review found that opioid use for acute pain (i.e., pain with abrupt onset and caused by an injury or other process that is not ongoing) is associated with long-term opioid use, and that a greater amount of early opioid exposure is associated with greater risk for long-term use.  Several guidelines on opioid prescribing for acute pain from emergency departments and other settings have recommended prescribing ≤3 days of opioids in most cases, whereas others have recommended ≤7 days or <14 days. Because physical dependence on opioids is an expected physiologic response in patients exposed to opioids for more than a few days, limiting days of opioids prescribed also should minimize the need to taper opioids to prevent distressing or unpleasant withdrawal symptoms. Experts noted that more than a few days of exposure to opioids significantly increases hazards, that each day of unnecessary opioid use increases likelihood of physical dependence without adding benefit, and that prescriptions with fewer days’ supply will minimize the number of pills available for unintentional or intentional diversion.

Experts agreed that when opioids are needed for acute pain, clinicians should prescribe opioids at the lowest effective dose and for no longer than the expected duration of pain severe enough to require opioids to minimize unintentional initiation of long-term opioid use. Experts thought, based on clinical experience regarding anticipated duration of pain severe enough to require an opioid, that in most cases of acute pain not related to surgery or trauma, a ≤3 days’ supply of opioids will be sufficient. For example, in one study of the course of acute low back pain (not associated with malignancies, infections, spondylarthropathies, fractures, or neurological signs) in a primary care setting, there was a large decrease in pain until the fourth day after treatment with paracetamol, with smaller decreases thereafter. Some experts thought that because some types of acute pain might require more than 3 days of opioid treatment, it would be appropriate to recommend a range of ≤3–5 days or ≤3–7 days when opioids are needed. Some experts thought that a range including 7 days was too long given the expected course of severe acute pain for most acute pain syndromes seen in primary care.

Opioid treatment for post-surgical pain is outside the scope of this guideline. Clinicians should not prescribe additional opioids to patients “just in case” pain continues longer than expected. Clinicians should re-evaluate the subset of patients who experience severe acute pain that continues longer than the expected duration to confirm or revise the initial diagnosis and to adjust management accordingly

Experts agreed that opioids should not be considered first-line or routine therapy for chronic pain (i.e., pain continuing or expected to continue >3 months or past the time of normal tissue healing) outside of active cancer, palliative, and end-of-life care, given small to moderate short-term benefits, uncertain long-term benefits, and potential for serious harms; although evidence on long-term benefits of nonopioid therapies is also limited, these therapies are also associated with short-term benefits, and risks are much lower. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. This does not mean that patients should be required to sequentially “fail” nonpharmacologic and nonopioid pharmacologic therapy before proceeding to opioid therapy. Rather, expected benefits specific to the clinical context should be weighed against risks before initiating therapy. In some clinical contexts (e.g., headache or fibromyalgia), expected benefits of initiating opioids are unlikely to outweigh risks regardless of previous nonpharmacologic and nonopioid pharmacologic therapies used. In other situations (e.g., serious illness in a patient with poor prognosis for return to previous level of function, contraindications to other therapies, and clinician and patient agreement that the overriding goal is patient comfort), opioids might be appropriate regardless of previous therapies used. In addition, when opioid pain medication is used, it is more likely to be effective if integrated with nonpharmacologic therapy. Nonpharmacologic approaches such as exercise and CBT should be used to reduce pain and improve function in patients with chronic pain. Nonopioid pharmacologic therapy should be used when benefits outweigh risks and should be combined with nonpharmacologic therapy to reduce pain and improve function.

If narcotics are prescribed some are better than others

Regarding specific opioids and formulations, as noted by FDA, there are serious risks of extended release long acting opioids, and the indication for this class of medications is for management of pain severe enough to require daily, around-the-clock, long-term opioid treatment in patients for whom other treatment options (e.g., nonopioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain. Time-scheduled opioid use was associated with substantially higher average daily opioid dosage than as-needed opioid use in one study. Methadone has been associated with disproportionate numbers of overdose deaths relative to the frequency with which it is prescribed for pain. Methadone has been found to account for as much as a third of opioid-related overdose deaths involving single or multiple drugs in states that participated in the Drug Abuse Warning Network, which was more than any opioid other than oxycodone, despite representing <2% of opioid prescriptions outside of opioid treatment programs in the United States; further, methadone was involved in twice as many single-drug deaths as any other prescription opioid.

When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. ER/LA opioids include methadone, transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine. The clinical evidence review found a fair-quality study showing a higher risk for overdose among patients initiating treatment with ER/LA opioids than among those initiating treatments with immediate-release opioids. When an ER/LA opioid is prescribed, using one with predictable pharmacokinetics and pharmacodynamics is preferred to minimize unintentional overdose risk. In particular, unusual characteristics of methadone and of transdermal fentanyl make safe prescribing of these medications for pain especially challenging.

Methadone should not be the first choice for an ER/LA opioid. Only clinicians who are familiar with methadone’s unique risk profile and who are prepared to educate and closely monitor their patients, including risk assessment for QT prolongation and consideration of electrocardiographic monitoring, should consider prescribing methadone for pain.

Regarding high-dose therapy-Consistent with the clinical evidence review, the contextual review found that opioid-related overdose risk is dose-dependent, with higher opioid dosages associated with increased overdose risk. In these four studies, compared with opioids prescribed at <20 MME/day, the odds of overdose among patients prescribed opioids for chronic nonmalignant pain were between 1.3 (67) and 1.9 (24) for dosages of 20 to <50 MME/day, between 1.9 (67) and 4.6 (24) for dosages of 50 to <100 MME/day, and between 2.0 (67) and 8.9 (66) for dosages of ≥100 MME/day. Compared with dosages of 1-<20 MME/day, absolute risk difference approximation for 50-<100 MME/day was 0.15% for fatal overdose (24) and 1.40% for any overdose (66), and for ≥100 MME/day was 0.25% for fatal overdose (24) and 4.04% for any overdose (66). A recent study of Veterans Health Administration patients with chronic pain found that patients who died of overdoses related to opioids were prescribed higher opioid dosages (mean: 98 MME/day; median: 60 MME/day) than controls (mean: 48 MME/day, median: 25 MME/day) (127). Finally, another recent study of overdose deaths among state residents with and without opioid prescriptions revealed that prescription opioid-related overdose mortality rates rose rapidly up to prescribed doses of 200 MME/day, after which the mortality rates continued to increase but grew more gradually

Regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. Three studies of fatal overdose deaths found evidence of concurrent benzodiazepine use in 31%–61% of decedents. In one of these studies, among decedents who received an opioid prescription, those whose deaths were related to opioids were more likely to have obtained opioids from multiple physicians and pharmacies than decedents whose deaths were not related to opioids.

Regarding duration of use, patients can experience tolerance and loss of effectiveness of opioids over time. Patients who do not experience clinically meaningful pain relief early in treatment (i.e., within 1 month) are unlikely to experience pain relief with longer-term use.

Which clients should rarely be prescribed opioids?

Certain risk factors are likely to increase susceptibility to opioid-associated harms and warrant incorporation of additional strategies into the management plan to mitigate risk. Clinicians should assess these risk factors periodically, with frequency varying by risk factor and patient characteristics. Other factors vary more frequently over time, such as alcohol use, history of overdose, history of substance use disorder, higher dosages of opioids (≥50 MME/day), and concurrent use of benzodiazepines with opioids, are present.

Regarding populations potentially at greater risk for harm, risk is greater for patients with sleep apnea or other causes of sleep-disordered breathing, patients with renal or hepatic insufficiency, older adults, pregnant women, patients with depression or other mental health conditions, and patients with alcohol or other substance use disorders. Opioid therapy can decrease respiratory drive, a high percentage of patients on long-term opioid therapy have been reported to have an abnormal apnea-hypopnea index, opioid therapy can worsen central sleep apnea in obstructive sleep apnea patients, and it can cause further desaturation in obstructive sleep apnea patients not on continuous positive airway pressure (CPAP). Reduced renal or hepatic function can result in greater peak effect and longer duration of action and reduce the dose at which respiratory depression and overdose occurs.  Age-related changes in patients aged ≥65 years, such as reduced renal function and medication clearance, even in the absence of renal disease, result in a smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose. Older adults might also be at increased risk for falls and fractures related to opioids. Opioids used in pregnancy can be associated with additional risks to both mother and fetus. Some studies have shown an association of opioid use in pregnancy with birth defects, including neural tube defects, congenital heart defects, preterm delivery, poor fetal growth, and stillbirth. Importantly, in some cases, opioid use during pregnancy leads to neonatal opioid withdrawal syndrome. Patients with mental health comorbidities and patients with histories of substance use disorders might be at higher risk than other patients for opioid use disorder. Recent analyses found that depressed patients were at higher risk for drug overdose than patients without depression, particularly at higher opioid dosages, although investigators were unable to distinguish unintentional overdose from suicide attempts.

Because psychological distress frequently interferes with improvement of pain and function in patients with chronic pain, using validated instruments such as the Generalized Anxiety Disorder (GAD)-7 and the Patient Health Questionnaire to assess for anxiety, post-traumatic stress disorder, and/or depression, might help clinicians improve overall pain treatment outcomes. Experts noted that clinicians should use additional caution and increased monitoring to lessen the increased risk for opioid use disorder among patients with mental health conditions (including depression, anxiety disorders, and PTSD), as well as increased risk for drug overdose among patients with depression. Previous guidelines have noted that opioid therapy should not be initiated during acute psychiatric instability or uncontrolled suicide risk, and that clinicians should consider behavioral health specialist consultation for any patient with a history of suicide attempt or psychiatric disorder. In addition, patients with anxiety disorders and other mental health conditions are more likely to receive benzodiazepines, which can exacerbate opioid-induced respiratory depression and increase risk for overdose. Clinicians should ensure that treatment for depression and other mental health conditions is optimized, consulting with behavioral health specialists when needed. Treatment for depression can improve pain symptoms as well as depression and might decrease overdose risk.

Illicit drugs and alcohol are listed as contributory factors on a substantial proportion of death certificates for opioid-related overdose deaths.

Dangers of cutting off narcotics or not prescribing at all.

Concerns have been raised that prescribing changes such as dose reduction might be associated with unintended negative consequences, such as patients seeking heroin or other illicitly obtained opioids or interference with appropriate pain treatment. With the exception of a study noting an association between an abuse-deterrent formulation of OxyContin and heroin use, showing that some patients in qualitative interviews reported switching to another opioid, including heroin, for many reasons, including cost and availability as well as ease of use.

Opioids are cheaper than the alternate treatment choices.

Although there are perceptions that opioid therapy for chronic pain is less expensive than more time-intensive nonpharmacologic management approaches, many pain treatments, including acetaminophen, NSAIDs, tricyclic antidepressants, and massage therapy, are associated with lower mean and median annual costs compared with opioid therapy (174). COX-2 inhibitors, SNRIs, anticonvulsants, topical analgesics, physical therapy, and CBT are also associated with lower median annual costs compared with opioid therapy (174). Limited information was found on costs of strategies to decrease risks associated with opioid therapy; however, urine drug testing, including screening and confirmatory tests, has been estimated to cost $211–$363 per test (175).

 Once a patient starts opioid medications, when should they stop?

Pain lasting longer than 3 months or past the time of normal tissue healing (which could be substantially. Clinicians often write prescriptions for long-term use in 30-day increments, and opioid prescriptions written for ≥30 days are likely to represent initiation or continuation of long-term opioid therapy. Before writing an opioid prescription for ≥30 days, clinicians should establish treatment goals with patients. Clinicians seeing new patients already receiving opioids should establish treatment goals for continued opioid therapy.

Goals should center around pain and function. Monitoring progress toward patient-centered functional goals (e.g., walking the dog or walking around the block, returning to part-time work, attending family sports or recreational activities) can also contribute to the assessment of functional improvement. Clinicians should use these goals in assessing benefits of opioid therapy for individual patients and in weighing benefits against risks of continued opioid therapy. If patients receiving opioid therapy for chronic pain do not experience meaningful improvements in both pain and function compared with prior to initiation of opioid therapy, clinicians should consider working with patients to taper and discontinue opioids and should use nonpharmacologic and nonopioid pharmacologic approaches to pain management.

If patients do not experience improvement in pain and function at ≥90 MME/day, or if there are escalating dosage requirements, clinicians should discuss other approaches to pain management with the patient, consider working with patients to taper opioids to a lower dosage or to taper and discontinue opioids.

Established patients already taking high dosages of opioids, as well as patients transferring from other clinicians, might consider the possibility of opioid dosage reduction to be anxiety-provoking, and tapering opioids can be especially challenging after years on high dosages because of physical and psychological dependence. However, these patients should be offered the opportunity to re-evaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. Clinicians should explain in a nonjudgmental manner to patients already taking high opioid dosages (≥90 MME/day) that there is now an established body of scientific evidence showing that overdose risk is increased at higher opioid dosages.

Clinicians should empathically review benefits and risks of continued high-dosage opioid therapy and should offer to work with the patient to taper opioids to safer dosages. For patients who agree to taper opioids to lower dosages, clinicians should collaborate with the patient on a tapering plan. Experts noted that patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages. Clinicians should remain alert to signs of anxiety, depression, and opioid use disorder that might be unmasked by an opioid taper and arrange for management of these co-morbidities.

When opioids are started, clinicians should prescribe the lowest effective dosage.

Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day. Benefits of high-dose opioids for chronic pain are not established. This randomized trial found no difference in pain or function between a more liberal opioid dose escalation strategy and maintenance of current dosage. At the same time, risks for serious harms related to opioid therapy increase at higher opioid dosage. The clinical evidence review found that higher opioid dosages are associated with increased risks for motor vehicle injury, opioid use disorder, and overdose (KQ2). The clinical and contextual evidence reviews found that opioid overdose risk increases in a dose-response manner, that dosages of 50–<100 MME/day have been found to increase risks for opioid overdose by factors of 1.9 to 4.



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