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Responding to requests for opioid analgesics from patients with chronic pain

Read time: 10 mins
Last updated:9th Aug 2022
Published:9th Aug 2022
Author: Article by Simon van Rysewyk, PhD; Associate Director (Medical Writing) at EPG Health

When patient requests for opioids place the patient at risk of harm, the HCP should use strategies for declining such requests. This short article provides sample responses that the HCP can use, or adapt to their purposes, for replying to inappropriate opioid requests.

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Article by Simon van Rysewyk, PhD; Associate Director (Medical Writing) at EPG Health

Introduction

Health care professionals (HCP) can find it challenging interacting with patients with chronic pain who request opioid analgesics1–9.

Most patients do not request opioid analgesics from their HCPs, contrary to popular or clinical depictions of chronic pain patients as ‘drug-seekers’. When patients do request opioid analgesics, they tend to use mitigation, indirection, or deference, as their preferred strategies. Such patients present themselves as deserving to receive opioids, while respecting HCP autonomy8.

Patients participate in the clinical encounter with a variety of expectations and priorities. A desire for an opioid analgesic may be only part of the patient’s story. It is therefore important for the HCP to devote resources to evaluating patient priorities and expectations for chronic pain treatment8–10.

When patient requests for opioids place the patient at risk of harm, the HCP should use strategies for declining such requests. This short article provides sample responses that the HCP can use, or adapt to their purposes, for replying to inappropriate opioid requests.

Considerations for declining patient requests for opioids

In declining such patient requests, it is important that the HCP explain why he or she cannot provide what the patient wants. This can help the patient understand why the HCP made the decision.

Even when the patient does not agree with the HCP’s decision, the explanation offered to the patient shows a clear position based on safety and compassion, rather than personal whim.

The HCP should offer the patient alternatives, including opioid substitution treatment, which the patient may start in the future. The HCP needs to recognise that the medications the patient has requested have a meaningful role in the patient’s life, and asking the patient to act differently can be difficult, or impossible.

Practice or clinic staff should agree on, and follow, a policy on medications that can place patients at risk of harm. For example:

Pain Medication Policy

Excluding terminal cancer, our policy is that we will not prescribe ‘painkiller’ medicines:

• At your first appointment
• On a phone request
• Without a proper assessment
• Over the long term

Sample responses to patient requests for opioids

The HCP can develop ‘scripts’ in response to inappropriate requests for opioids. For new patients, the practice administrator or nurse and the doctor can convey the messages.

I want to help you. However, we have a practice policy that we do not provide opioid medications to new patients. I will undertake a comprehensive assessment and seek information from your previous health team. I will not be giving you a prescription today.
Doctor
The doctor, when seeing you for the first time, will do a detailed assessment and may need information from your previous doctors before making any treatment decisions, including prescribing medicines.
Practice administrator or nurse

Explain why you are unwilling to give opioid prescriptions

Doctors need to be able to explain why they are not willing to give prescriptions for opioid analgesics.

We are now aware that these medicines can cause significant and serious side effects. So, we are very cautious about prescribing them. It has become clear that opioids can be ineffective in the long-term treatment of chronic pain. The risks of opioid treatment generally outweigh the benefits, and people do better with other options. I’m happy to discuss these options with you.
Doctor

In requesting opioids from HCPs, patients may use these statements:

  • “I can’t cope without it”
  • “I need this for my pain”
  • “I’m using the drugs to detox, they really help”
  • “I’ve tried everything else, nothing else works”
  • "You’ll force me to go out and buy drugs”
  • “You’ve given them to me in the past, why won’t you give them to me now?”

There are various responses that doctors can make to these kinds of patient statements.

I understand that you’re struggling with this. However, we now know that the use of this medication is not the best approach to help people to improve and maintain their health and wellbeing. I want to help, but can only do what is effective and safe.
Doctor
I am not prepared to prescribe these medicines in the way you suggest. These medicines have a risk, and I need to create greater safety by changing the way this medicine is prescribed.
Doctor
I want to help you, but I cannot continue to prescribe this medication in this way, as I am concerned that you may come to harm.
Doctor
I am concerned for your safety and think these medicines may be causing you harm. I think you have become dependent, and there are other options that may work better. I am going to ask for advice from an addiction specialist and suggest treatment changes, which may include referral or alternative medications, including opioid substitution treatment.
Doctor
I can’t prescribe that medication because of government regulations. However, I do want to help you and can offer other, safer options.
Doctor

View more Medthority Original Content on opioid prescribing for chronic noncancer pain in general practice.

References

  1. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10(2):113-130.e22.
  2. The Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice. 2020 https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/drugs-of-dependence. Accessed 27 July 2022.
  3. National Institute for Healthcare and Clinical Excellence. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE Guidelines. 2021;(April):NICE guideline [NG193].
  4. Häuser W, Morlion B, Vowles KE, Bannister K, Buchser E, Casale R, et al. European clinical practice recommendations on opioids for chronic noncancer pain – Part 1: Role of opioids in the management of chronic noncancer pain. Eur J Pain. 2021;25(5):949–968.
  5. KrĨevski ŠkvarĨ N, Morlion B, Vowles KE, Bannister K, Buchsner E, Casale R, et al. European clinical practice recommendations on opioids for chronic noncancer pain – Part 2: Special situations. Eur J Pain (United Kingdom). 2021;25(5):969–985.
  6. 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. Accessed 27 July 2022.
  7. Busse JW, Craigie S, Juurlink DN, Buckley DN, Li W, Couban RJ, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;189(18):E659–E666.
  8. Buchbinder M, Wilbur R, McLean S, Sleath B. “Is there any way I can get something for my pain?” Patient strategies for requesting analgesics. Patient Educ Couns. 2015;98(2):137–143.
  9. Matthias MS, Johnson NL, Shields CG, Bair MJ, MacKie P, Huffman M, et al. “I’m Not Gonna Pull the Rug out From Under You”: Patient-Provider Communication About Opioid Tapering. J Pain. 2017;18(11):1365–1373.
  10. Matthias MS, Talib TL, Huffman MA. Managing Chronic Pain in an Opioid Crisis: What Is the Role of Shared Decision-Making? Health Commun. 2020;35(10):1239–1247.
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