But there are cases in which judgment should trump math, such as when converting from an IV to an oral regimen. We frequently see patients in the clinic requesting refills for more than 100 mg of hydromorphone because “that’s what I was on when I was hospitalized and on the pump.” If the IV-to-oral conversion leaves you prescribing high doses of oral opioids, plan for a rapid taper and a smooth handoff to the outpatient setting.
One strategy to decrease an error in math and judgment is to use IV PCAs as infrequently as possible if a patient isn’t post-operative and they are able to take oral meds. And never hesitate to consult with your inpatient pharmacist or a chronic pain specialist.
For a low-risk chronic pain patient on low-dose opioids, don’t change the regimen, even if the indication for opioids isn’t clear.
Although it is tempting to become an opioid prohibitionist, if a patient has been taking an opioid for years and is functioning, working, compliant, and has no risk factors for complications from COT, it is likely fine to continue their current regimen. Touch base with the primary opioid prescriber, and if you’re concerned, use some of the monitoring instruments described earlier (PMP, urine drug screen, opioid treatment agreement, pill counts).
If a patient has pain all the time, they need to be on a medication that works all the time.
A good pain history followed by a good neurological and mental health assessment is of incalculable value, especially because physicians often underestimate a patient’s pain intensity and its impact on a patient’s quality of life.5,6 A patient’s pain intensity, quality of life, and function can be dramatically improved by starting a long-acting medication for “constant pain.”
If a patient hurts “24 hours a day” and cannot function on hydrocodone/acetaminophen 10/325 QID, it’s probably because they are constantly reacting to spikes in pain and using a “some of the time” medicine to treat “all the time” pain. Switching to a long-acting medication—and it doesn’t have to be an opioid—could improve control and decrease how much narcotic the patient needs.
If you choose a long-acting opioid (in this case, you could try morphine sulphate extended-release 15 mg BID and satisfy 50% of the hydrocodone need), then you could titrate slowly upwards to where the patient would not need hydrocodone. If the patient still had uncontrolled pain, then either morphine is the wrong compound for them or they are benefiting from the “nonanalgesic properties” of the opioids.
Give the patient the benefit of the doubt; because of genetic polymorphisms, a patient may need several opioid rotations before the right opioid compound is found.
Dr. Schultz is a hospitalist and assistant professor in the department of internal medicine at the University of Miami Miller School of Medicine. She is board-certified in hospice and palliative care and specializes in chronic pain management. Dr. Ajam is a hospitalist and a clinical assistant professor in the department of anesthesiology at Wake Forest University Baptist Medical Center and the Carolinas Pain Institute. He is board-certified in chronic pain management.
- Garrettson M, Ringwalt C. An evaluation of the North Carolina controlled substances reporting system: part II impact evaluation, January 2013. PDMP Center of Excellence website. Available at: http://pdmpexcellence.org/sites/all/pdfs/NC_control_sub_eval_pt_2.pdf. Accessed Sept. 3, 2013.
- Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005, national vital statistics reports; Vol. 56 No. 10. Hyattsville, Md.: National Center for Health Statistics; 2008.
- Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980;302(2):123.
- American Society of Addiction Medicine; personal communication, 2013.
- Mäntyselkä P, Kumpusalo E, Ahonen R, Takala J. Patients’ versus general practitioners’ assessments of pain intensity in primary care patients with non-cancer pain. Br J Gen Pract. 2001;51(473):995-997.
- Petersen MA, Larsen H, Pedersen L, Sonne N, Groenvold M. Assessing health-related quality of life in palliative care: comparing patient and physician assessments. Eur J Cancer. 2006;42(8):1159-1166.