Making opioid prescribing safer: time for a checklist?

ISSN 1758-1869 10.2217/PMT.11.30 © 2011 Future Medicine Ltd Pain Manage. (2011) 1(4), 279–285 The safety of opioid analgesics is cur­ rently the subject of considerable medi­ cal, public and governmental scrutiny [101]. This attention to a class of medicines used for millennia, with well known ben­ eficial and harmful effects, stems largely from a recent (relatively speaking) change in the therapeutic use of opioids. Efforts to promote improved pain control over the past decades resulted in greater accep­ tance and use of opioids with (hopefully) better pain management and less ‘fear’ of these agents in both cancer and non­ cancer­related pain, producing a dramatic increase in the number of opioid prescrip­ tions in the USA [1]. A consequence of this wider use has been a dramatic increase in patient encounters for opioid adverse patient events, diversion to non­medical uses, misuse and abuse [101]. The limita­ tions and hazards of opioids in the treat­ ment of chronic noncancer pain have been recognized and consensus guide­ lines for use have been developed [2]. In response to the public health problem of widespread misuse of opioids, the White House has developed a ‘Prescription Drug Abuse Prescription Plan’ that includes a US FDA Risk Evaluation and Mitigation Strategy (REMS), and potentially, educa­ tional requirements for obtaining a Drug Enforcement Agency (DEA) license [101]. Despite the many problems with opio­ ids, they remain key tools in the man­ agement of pain, and are unlikely to be replaced in the near future by safer, less abuse prone or more effective agents. Thus, most clinicians will continue to use opioids in their practices, and the only available approach to the ‘opioid problem’ is to improve the way these drugs are used. Our experience [3], and others [4], suggest that the adverse outcomes observed with opioid use are the result of multiple fac­ tors, including suboptimal patient assess­ ment, therapeutic planning, opioid choice and use, monitoring and patient educa­ tion, and errors in executing a proper prescription. Prescribing errors and defi­ ciencies are not unique to opioids, but as a ‘high­alert’ drug class [5], opioids clearly present a more serious risk of harm than most other drug classes. A primary focus of the White House plan is the education of care providers in the proper use of opioids and other abuse prone drugs [1]. The effectiveness of these efforts will likely be determined by their