Policy Expert Shares Tips for Managing Patients on Opioids. (Curbing Drug Abuse)

By Brunk, Doug | Clinical Psychiatry News, March 2003 | Go to article overview

Policy Expert Shares Tips for Managing Patients on Opioids. (Curbing Drug Abuse)


Brunk, Doug, Clinical Psychiatry News


LAS VEGAS-When prescribing opicids for chronic pain, make sure to set dear rules and expectations for yourself and your patient, including an agreement that both of you sign, Dr. Sidney Schnoll advised at the annual meeting of the American Academy of Addiction Psychiatry.

It's very important for the patient to know what the expectations are for him and what he can expect from you as the prescribing physician, said Dr. Schnoll, a psychiatrist who is medical director of health policy for Purdue Pharma, Stamford, Conn.

This was one of several clinical pearls he shared about how to effectively manage patients taking opioids and other medications with drug abuse liability. Other pearls include the following:

* Set the dosage of medication at the appropriate level to treat the condition and titrate as necessary. "There is no maximum dose," said Dr. Schnoll, who is also a professor of psychiatry at the Virginia Commonwealth University, Richmond. "Go up until you either have side effects or a positive response." The best way to do this is to ask patients early on in therapy to rate their pain on a scale of 0-10. Ask them to not only rate their pain at its worst, he said, but also to estimate at what point on the scale they believe their pain is tolerable.

"That gives you an end point to which you titrate their medication," he explained. "Otherwise you're shooting in the dark. It also helps you to differentiate the patient who is taking their medication appropriately from the abuser."

* Give patient enough medication for the next appointment plus rescue doses. Why rescue doses? "A lot of things can exacerbate pain, such as a fight with a spouse [or] a change in weather," he said. "One of the most common things I've found with my patients is that once they start to feel better, they go out and shovel the snow [or] rake the leaves. Their pain would go away with the increased physical activity [and then become exacerbated], so they needed to take the rescue dose."

* Ask the patient to bring in all original medical bottles with or without medication. Other ways to help differentiate patients who are abusing their medication from those taking it legitimately are to ask these questions: Was the prescription filled within a reasonable time after it was written? …

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