Opioid Risk Management

Abstract

This is a pocket book designed for the American market and addresses the essentials of safe prescribing of opioids in chronic pain. The fact that the book is on its second edition demonstrates its usefulness in this market. In the USA, there was a well-documented explosion in opioid prescribing for chronic non-cancer pain during the 1990s and excess deaths soon began to emerge. An editorial in the New England Journal of Medicine described the situation in 2010 as ‘a flood of opioids: a rising tide of deaths' when much stricter controls were introduced on prescribing by the Federal Drug Administration (FDA) via a Risk Evaluation and Mitigation Strategy (REMS). This book in part reflects the REMS and it is important to see the book in this context. The greatest correlation between problems and deaths occurred with oxycodone and methadone. Clear risk factors emerged from the disaster. It was found that patient factors such as history of an addiction disorder or anxiety/depression and physician factors such as high doses and immediate-release opioids could have predicted problems. This guide focuses on those risk factors and selection of those who may benefit from opioids and undoubtedly brings all the key elements of a REMS together in one place. A similar situation appears to be emerging in the UK with an excess of prescribing of all opioids in chronic non-cancer pain. Tramadol has been mainly associated with an excess of deaths leading to its being classified as a controlled drug. Guidelines for safe opioid prescribing already exist in the UK with less of a focus on structured risk assessment and more on a holistic assessment. This guide offers a much more rigid framework than is usual UK practice. Its aims are to focus solely on risk management. I especially liked the screening tools that are suggested for use. The mnemonics are useful such as the four A's of pain management (analgesia, activities of daily living, adverse events, aberrant behaviours). I especially liked the inclusion of the DIRE (Diagnosis, Intractability, Risk, Efficacy) tool which is an interesting mnemonic in itself—how bad does it have to be before you are likely to do well with strong opioids? The answer from this tool is that the pain might be bad, but your life cannot be a mess. The SOAPP (Screener and Opioid Assessment for Patients with Pain) test is widely used. The section on urine testing covers an area that practising UK pain doctors will be less familiar with. The less useful elements with UK practice are the opioid contracts which are written out in full taking up many pages. Whether signing such a contract prevents the problems seen is questionable—people have to understand and own their medicines and the physician has to exercise clinical judgement in selecting patients. This particular reviewer has never found contracts to be of great benefit. The outcomes section is very thin and out of step with British Pain Society guidance which recommends functional improvement as a more objective outcome than pain relief. Additionally, I would have liked to have seen more of the story behind the need for this book explained. For a pocket guide, it squeezes a lot in and there is much to absorb. Given the potential for harm and indeed strong evidence for an increasing problem with opioids, the tools contained in this book should admirably equip practitioners everywhere with the knowledge to prescribe safely. In the UK, the bulk of opioid prescribing is carried out in primary care. However, given the length of time that it takes to complete the screening tools and the extensive documentation of progress recommended, in this guide, it is likely that it would take either a change in the law or financial incentives for this approach to become routine. I would recommend this book in the first instance to specialists and trainees in pain medicine to ensure that they at least become familiar with screening for risk and benefit for opioids and embed it within their practice. Would I take it in my pocket? Probably not. Its focus is too narrow and lacks some of the information I need when supervising a switch from multiple high-dose opioids on the wards and in outpatients where the risks have been missed all too often.