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Opioid Prescribing Best Practices: Warning Signs, Tapering Strategies, and Alternatives
Psych Congress Steering Committee Member Arwen Podesta, MD, ABPN, FASAM, ABIHM, is a New Orleans-based psychiatrist who specializes in forensic psychiatry, addiction medicine, and holistic and integrative medicine. Dr Podesta is a distinguished fellow with the American Society of Addiction Medicine and with the American Psychiatric Association, as well as a recent past president of the Louisiana Society of Addiction Medicine.
In Part 2 of this interview from the recent Psych Congress 2021 meeting in San Antonio, Dr Podesta discusses warning signs that clinicians should look for with regard to potential opioid misuse or addiction in pain patients, tapering strategies for patients who have been prescribed opioids, and opioid alternatives for patients who are at a heightened risk for addiction.
Read the transcript:
Dr Arwen Podesta: For those suffering from pain and also taking opioids for pain, and also, let’s think about those on benzodiazepines and other scheduled medications as well, because it’s not just opioids that we’re worried about. If someone is filling their prescriptions early, is taking too many prescriptions, if there’s any red flags that might make you think that they’re sharing their medicine with someone else, asking for prescriptions from multiple doctors, you have all of the data in front of you if you connect with it.
Get your PDMP. Call the other prescribers working with the patient. Have a unified treatment plan with other physicians and other prescribers, and perhaps, the therapists as well, and also make sure that you can acquire collateral information if that’s available, such as family members and other people in the household.
A tapering strategy is something that some clinicians prepare for. When someone is being put onto an opioid, whether it’s a full-agonist opioid such as oxycodone or hydrocodone for direct pain management, or a partial agonist such as buprenorphine, or a full-agonist for opioid use disorder such as methadone, it’s imperative that you know how to land the plane.
If you’re going to fly the plane, let’s know how to land the plane. Let’s know how to get people off of that medicine. However, letting the patient know that that’s your plan can cause a lot of anxiety. When I’m starting someone on buprenorphine, they’re usually not in the best of mindset. They’re feeling funky, they might not feel very good, they might have a lot of anxiety. I discussed briefly with them that eventually, we’re going to talk about whether or not we want to stop this medicine, but every visit, we’re going to have that discussion briefly. I don’t have a plan in place for them. I don’t have an end mark like, “Oh, we’re going to do this medicine for 6 months.” No, it’s clinically based. It’s based on symptoms, based on all the other surroundings. Based on whether the root cause has been well treated, and if not, then we may maintain the medication for longer periods of time.
For those that do suffer from chronic pain and have a heightened risk for addiction, opioids are not contraindicated, as long as you’re working with a good pain management specialist that is aware that the patient might have risk. Utilizing those tools, being able to see red flags, having higher accountability is important.
However, that being said, not all pain is going to respond to a full-agonist opioid or a partial-agonist opioid. There are tons of other things that you can use in addition to or instead of, particularly non-pharmaceuticals such as counseling, pacing activities, cognitive behavioral therapy, mindfulness-based stress reduction, yoga, meditation, bodywork, etc. Interventional techniques that pain management specialists would do. Injections, facet nerve blocks, and then, of course, there are other medications. SSRIs, SNRIs, amitriptyline, and a whole bunch of AEDs, such as gabapentin and valproic acid, and others.
