Managing opioid prescribing in the ‘inherited’ patient with pain

The ‘inherited’ patient with chronic pain is a common challenge faced in general practice or in specialist clinics

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Pain management in the ‘inherited’ patient

The ‘inherited’ patient – one who switches to a new doctor – is often encountered in general practice or in specialist pain clinics^1-5.

Some inherited patients present to their new general practitioner (GP) without the benefit of a formal clinical handover (e.g., a referral letter)¹. This situation exposes the patient and GP to increased risk, especially in relation to assessment and selection of opioid analgesics.

The principles that apply for people with chronic non-cancer pain (CNCP) initiating an opioid trial also apply to managing the inherited patient, particularly one taking ≥100 mg/day oral morphine equivalent^1-5.

Conduct a biopsychosocial reassessment (over time)

• Bio – Assess for an underlying treatable condition, if suspected based on clinical ‘red-flags’ (e.g., inflammation, infection, neuropathology)
• Psycho – Evaluate the impact of pain on daily life (work, recreation), fatigue, and sleep
• Social – Assess the effects of pain on relationships and life events

Review the opioids in the inherited patient

In reviewing the current opioid analgesics for an inherited patient with CNCP, the GP decides whether it is¹:

• Rational – Evidence base for the opioids
• Defensible – Opioids are supported by legislation
• Confirmed – Confirm patient’s medication listing with previous provider to avert ‘prescription shopping’
• Comfort – GP is comfortable prescribing current opioids

The GP must decide if the inherited opioids will continue unchanged, continue with modification, or be discontinued. All decisions regarding treatment should be documented. Continuing with modification or discontinuing is an opportunity for the clinician to establish a new ‘opioid trial agreement’ with the patient.

Create a contract for new opioids

A new ‘opioid trial agreement’ between the GP and the inherited patient with CNCP should emphasise personalised goals that improve function and comfort, frequent review intervals (every three-months for stable patients), dose tapering if goals are not met, and regular medication monitoring (e.g., pill counts), among others.

Click the link for more information on the opioid trial agreement in the pain setting

Trialling new opioids in the inherited patient

When conducting an opioid trial in the inherited patient with CNCP, the opioid(s) that the patient is currently taking are converted to a non-parenteral opioid and dosing gradually altered to achieve full conversion to the new main opioid^1-5. For example:

• Week 1: 80% current opioids, 20% new opioid
• Week 2: 60% current opioids, 40% new opioid
• Week 3: 40% current opioids, 60% new opioid
• Week 4: 20% current opioids, 80% new opioid

Full conversion to the new opioid may require months if the patient prefers the current opioid more than its convert. In this scenario, the GP could increase the dose of the new opioid. The dose of the convert is the lowest dose that maintains daily function, reduces discomfort, with minimal side effects. For various reasons, the current opioids may not achieve complete withdrawal in the patient. This is not necessarily a clinical problem if the patient is as active as he or she wishes to be.

Perform frequent 5A criteria assessment

Regularly reassess the inherited patient with CNCP, weekly initially, then according to achievement of goals, according to the 5A criteria⁵:

• Analgesia
• Activity
• Adverse effects
• Affect
• Aberrant behaviour

Conclusion

In managing the inherited patient with chronic non-cancer pain, the GP should conduct a biopsychosocial reassessment of the patient, review the rationality and legality of the ‘inherited’ opioid analgesics, and choose to continue, modify, or discontinue the current drugs. Continuing the current opioids with modification or ceasing their use is an opportunity to set a new medication agreement. Opioid pharmacotherapy for patients with chronic pain is always an ongoing trial, repeatedly revisiting the question, ‘Is this patient’s situation opioid-responsive?’ Using the 5A criteria, the GP needs to carefully weigh the ongoing role of opioid analgesics for the inherited patient with pain.

References:

1. Grinzi P. The inherited chronic pain patient. Austral Fam Physic. 2016;45(12):868–872.
2. Gourlay DL, Heit HA. Universal precautions revisited: managing the inherited pain patient. Pain Med. 2009;10(2):S115–123.
3. Coffin PO, Barreveld AM. Inherited Patients on Opioids for Chronic Pain-Considerations for Primary Care. N Engl J Med. 2022;386(7):611.
4. The Royal Australian College of General P. Prescribing drugs of dependence in general practice. 2020. Available at: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/drugs-of-dependence.
5. Faculty of Pain Medicine. Australian and New Zealand College of Anaestheists. Statement regarding the use of opioid analgesics in patients with chronic non-cancer pain. 2021. https://www.anzca.edu.au/getattachment/7d7d2619-6736-4d8e-876e-6f9b2b45c435/PS01(PM)-Statement-regarding-the-use-of-opioid-analgesics-in-patients-with-chronic-non-cancer-pain.