From the American College of Physicians:
Opioid Use Suggested for Pain Management

April 7, 2003 -- Physicians should consider the use of narcotics for chronic pain, according to Michael E. Preodor, MD, president of Horizon Hospice in Chicago, Illinois. The medical profession has long known how to use opioids safely and effectively, he told attendees at the 2003 Annual Session of the American College of Physicians, held here April 3-5. Yet they are underused, because of clinicians' concerns about legal issues and the public's fear of addiction, he maintained.

"Our hopes are that by responding to the fears that physicians and the public may have about the use of narcotics, we can allow adequate access to and application of narcotics for pain management," he said. Opioids do not cause long-term impairment of the central nervous system or psychological damage, according to Dr. Preodor. They also cause less immune impairment than does chronic pain, he said, describing addiction as a rare event. Where more research is needed, he said, is in their long-term use for chronic conditions.

"I absolutely think there's a role for narcotics in non-malignant pain," he said. However, he cautioned, "it's a much harder topic -- dealing with an arthritic patient who may be taking narcotics for 20 years. Do we know how to dose that correctly? Do we know if that's safe? We're not quite there yet."

He said the use of methadone as an alternative to morphine also needs more research. Methadone has a unique method of action that makes it superior to narcotics, especially for nerve-mediated pain, he said. It is difficult to use, however, because of drug interactions, side effects, and dosing issues.

"I'm not sure we know enough to recommend common use [of methadone]," Dr. Preodor said. "But thoughtful use, especially with the help of somebody who has experience with methadone, makes it a desirable alternative."

Citing guidelines from the Federation of State Medical Boards, he recommended that physicians take the following steps when prescribing narcotics for pain management:

  1. Document everything your do.
  2. Check the patient for history of substance abuse.
  3. Do a physical exam.
  4. Get a consultation from another physician if appropriate.
  5. Record a treatment plan.
  6. Document the functional status of the patient and what you are doing so that the person can be active in the community
  7. Have the patient sign an opioid agreement.

The opioid agreement spells out that only one pharmacy will fill prescriptions, no replacements will be issued if the patient loses the medication, and that the person will not call the physician on weekends.

"I am comfortable prescribing narcotics for 2 months as long as I see the patient every two months and review the plan," said Dr. Preodor.

By Jane Salodof MacNeil SAN DIEGO, CA

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