When will we ever learn? Extremes never work; rather, somewhere near the center of options lies the potential solution. Perhaps centering our patient care on the actual patient has been the answer all along.
The opioid crisis has reverberated throughout our society. An American dies approximately every 6 minutes from a drug overdose,1 while an American baby is born dependent on opioids approximately every 15 minutes.2 Although the vast majority of overdose deaths stem from illegal opioid substances,1 the conversations and concerns have rippled into countless pharmacy conversations. One thing remains a constant: the absolute need for all health care professionals to utilize best practices when prescribing opioids (or any controlled substance) within a diverse pain management or any treatment plan. That’s just common sense for providing safe and effective patient care, particularly for our patients in pain and/or recovery.
Some people, by far the minority, still struggle with considering substance use disorder—or addiction—a disease or a medical condition, beyond simplistic bad choices being made. Health care professionals need to check their opinions at the door and provide patient care to everyone in need in a manner that preserves their universal professional mantra of “Do no harm.” If a person experiences a 10th opioid overdose, would harm be done if that person is not revived with an opioid antagonist such as naloxone? Consider if someone choosing to eat high-fat, high-calorie, high-sugar food every day has multiple heart attacks, continually needing nitroglycerin to be saved. Would harm be done if a 10th nitro refill were refused to be dispensed?
Medications for opioid use disorder (MOUDs), including methadone, naltrexone, and buprenorphine, are improving and saving lives every single day across the globe, but a health care professional never proceeds with blind faith for any substance on this planet. MOUDs have shown success, but as with all medications, there are concerns. Buprenorphine has been in the spotlight for its observed misuse and abuse, which, as with any and every controlled substance, is an undeniable possibility, and it’s even stated in the package insert. That does not mean we should avoid its utilization, but it does mean that we can emphasize respect for its pharmacology. Stigma can overpower common sense, and to combat that, the term "community redistribution" emerged as a means to avoid the diversionary terms of misuse and abuse when a person is merely seeking treatment, often without even realizing it. Regardless of the terminology, MOUDs are valuable in improving and saving lives for those in recovery.
At the same time, over 1 billion people suffer from chronic pain, including approximately 100 million Americans, which is more than those affected by diabetes, heart disease, and cancer combined. Approximately 75 million Americans, 1 of every 4, have suffered from pain that lasts longer than 24 hours, and millions more suffer from acute pain. Chronic pain is the most common cause of long-term disability.3
Over the course of the past few decades, opioid medications have jumped from opiophobia to opiophilia and back. With respect to pain management, it’s been the best of times and the worst of times. The delicate balance between restrictions and openness aims to prevent unintended consequences, which, in the opioid crisis, means remembering not to facilitate people leaving our health care supply chain to enter the illicit substance supply chain.
Regardless of the Omnibus Budget Reconciliation Act of 1990 or the federally mandated corresponding legal responsibility for prescribers and dispensers to ensure a proper diagnosis and scope of practice,4,5 shouldn’t the professional expectation be to offer patient counseling proactively? While we’re at it, one can take a moment to recognize opioid best practices, which I take the liberty of grouping into 3 categories, including patient education, treatment selection, and adherence and diversion monitoring, as illustrated in Table.
Let’s touch on a few of these best practices. Besides "baby aspirin," is there a worse term in health care than "medicine cabinet"? Clinicians should remind patients to store all medications (not just controlled substances) in lockable safe boxes to keep them away from everyone and avoid the humidity and temperatures of a bathroom.
Regarding medication disposal, the US Environmental Protection Agency recommends Drug Enforcement Agency drug takeback days or the removal of identifiers and mixing with undesirable substances, but certainly never flushing a medication down the toilet.6 The FDA agrees but lists approximately 4 dozen controlled substances that should be flushed down the toilet when attempting disposal.7,8 One would expect harmony among the recommendations, but at least pharmacies can also register to become sites for the disposal of controlled substances.9
Treatment selection will typically begin with a diagnosis, which can often be complicated on the pain frontier, but for starters, the pain scale that I use for my patients in pain is the Defense and Veterans Pain Rating Scale (DVPRS), which combines the best of the best approaches to common pain scales, including color, emotional faces, and, of course, numbers.10 However, there are 4 powerful questions added that assess a patient’s activity, sleep, mood, and stress. Clinicians may be unable to help change a patient’s pain number; however, affecting at least 1 of these items is an impactful SMART (specific, measurable, achievable, relevant, time-bound) goal.
As for mental health screenings, the succinct Patient Health Questionnaire (PHQ)–2 asks 2 questions, including the frequency of having little or no interest in doing things and feeling down, depressed, or hopeless.11 If one screens a risk in the PHQ-2, a clinician can administer the PHQ-9 further to assess the need for a mental health professional referral.12 Additionally, opioid risk screenings should be used for all patients under consideration for or already receiving opioid therapy. There are many validated tools readily available for clinicians; some are to be administered by the health care provider, while the patient may complete others.13
