CAREFUL: A Practical Guide for Improving the Clinical Surveillance of Long-Term Opioid Therapy

Abstract

To the Editor: National prescribing guidelines for opioid use provide recommendations for clinical surveillance aimed at enhancing the safe use of these medications in patients with chronic pain.1Dowell D. Haegerich T.M. Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016.JAMA. 2016; 315: 1624-1645Crossref PubMed Scopus (2403) Google Scholar However, despite the widespread availability of these guidelines, most clinicians do not follow recommendations for clinical surveillance.2Tournebize J. Gibaja V. Muszczak A. Kahn J.P. Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence.Pain Pract. 2016; 16: 370-383Crossref PubMed Scopus (31) Google Scholar The purpose of this letter was to describe an acronym that provides a summary of many key components of clinical surveillance that have been recommended for patients receiving long-term opioid therapy. The Table depicts the terms of the CAREFUL acronym. Although opioid contracts are not legally binding documents, they outline shared responsibilities that should exist between the patient and the clinician regarding long-term opioid use. The risk of addiction should not only be assessed before initiation of long-term opioid therapy but also during the course of treatment to identify early signs and symptoms of opioid use disorder. Prescription drug monitoring programs (PDMPs) are available in all 50 states (plus the District of Columbia)3National Alliance for Model State Drug Laws.http://www.namsdl.org/Date accessed: April 10, 2018Google Scholar and PDMPs can aid verification of compliance with issued prescriptions for controlled substances. The opioid dose should be regularly assessed to ensure the effective lowest dose is being prescribed. Functionality, including pain, is an important clinical outcome of long-term opioid therapy, and measures of function and pain should be assessed and documented. Similar to PDMPs, urine drug screens can aid verification of medication compliance. Longitudinal follow-up is the cornerstone of clinical surveillance because all other recommendations are dependent, in part, on face-to-face encounters with the patient.TableThe CAREFUL Acronym for the Clinical Surveillance of Long-Term Opioid TherapyCContract for opioid useAAddiction riskRRx monitoring programsEEffective lowest doseFFunctionalityUUrine drug screenLLongitudinal follow-up Open table in a new tab Although the CAREFUL acronym can help operationalize many key recommendations for clinical surveillance, the decision to continue long-term opioid therapy is driven by the prescribing practices of individual clinicians. The principal characteristics of clinicians posited to influence opioid prescribing include (1) specialty area of practice; (2) previous training in pain medicine and opioid use; (3) attitudes and beliefs about the risks and benefits of opioids; and (4) perceived professional obligations to patients.4Hooten W.M. Brummett C.M. Sullivan M.D. et al.A conceptual framework for understanding unintended prolonged opioid use.Mayo Clin Proc. 2017; 92: 1822-1830Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar A pressing need exits to improve the clinical surveillance of patients receiving long-term opioid therapy for chronic pain. The CAREFUL acronym is a practical tool that could be used in daily clinical practice to guide the assessment and documentation of many key recommendations governing the clinical surveillance of patients receiving long-term opioid therapy for chronic pain.