Chronic Opioid Use: An Interactive Case History 2023

The following hypothetical case is intended to reflect the changes in the CDC opioid prescribing guidelines (see full background).¹ Below is a step-by-step guide through the management of “legacy” patients on chronic opioid medications. See our separate case on initiating opioid therapy under the new guidelines.

Martha is a 59-year-old chef with a past medical history of chronic depression, generalized anxiety disorder, and chronic axial low back pain, which has been slowly increasing. Martha denies any trauma, but reports a constant, dull, achy pain in a band-like distribution over her low back. She denies radicular symptoms. Pain is exacerbated with prolonged sitting, standing, and changing positions at night. She has tried injections to her sacroiliac joint in the past, with moderate yet temporary relief.

Current Medications

She has been compliant with the following medication regimen for the past 2 years:

• oxycodone/acetaminophen 10 mg/325 mg Q4hrs PRN
• cyclobenzaprine 10 mg at bedtime

She has not tried any neuropathic medications and is “skeptical” of antidepressants.

Psychiatric History

Martha was diagnosed with moderate chronic depression at age 25 years. She has a strong family history of depression. Her mother had been hospitalized several times for suicidal ideations and alcohol abuse. Martha states that she often feels “down” and limited in her enjoyment of activities partly due to chronic low back pain.

Martha has also struggled with irritable bowel syndrome (IBS) for most of her life. Her usual symptoms include constipation and cramps. She does not take any medications for the IBS.

Martha is 5 feet 6 inches tall and weighs 190 pounds. She stands for several hours a day due to her occupation and relaxes on the couch when she gets home.

Martha is recently divorced and moving to the city where you practice to “start a new life.” She’s presenting to your clinic for an initial visit and to establish care. She was previously seen by an outside pain medicine physician with mild control of her pain symptoms.

Q: Outside of medication, what would you initially suggest for Martha?

Sleep Hygiene

Chronic pain can have a significant impact on sleep quality, thus exacerbating chronic pain and creating a vicious cycle. We need to educate Martha on consistent sleep schedules, creating a sleep-conductive environment, and avoiding stimulating activities prior to bed.

A referral to a good psychotherapist, especially in the field of cognitive behavioral therapy (CBT), can be effective in managing chronic pain and quality of life by changing negative thought patterns and behaviors.

Anti-Inflammatory Diet

Several dietary changes can be made to help to reduce inflammation and alleviate chronic pain. Referring her to a skilled nutritionist to help incorporate foods that are high in omega-3 fatty acids (eg, fatty fish, flaxseeds, and walnuts) may help to reduce inflammation in the body. Additionally, incorporating plenty of fruits and vegetables into the diet can help to provide antioxidants and other nutrients that can help to reduce inflammation and promote healing.

Physical Therapy

Martha states that she trialed physical therapy 5 years ago for her low back pain but discontinued it after two sessions because of her rigorous work schedule. She should reestablish care with a local physical therapist to better improve body mechanics and structure.

The following prescription may serve as an example:

Dx: Sacroiliac Joint Pain. Please evaluate and treat 2 to 3x/week for 8 to 12 weeks. Focus on stretching of the hips and lower back to improve flexibility and reduce tension around the SI joint as well as strengthening target muscles in the hips, glutes, and lower back to improve stability and support around the SI joint. Please incorporate modalities such as heat or cold therapy, electrical stimulation, or ultrasound to reduce pain and inflammation. It is important that the patient be provided with home exercise programs and self-management strategies to maintain progress despite her work schedule.

Due to insurance coverage and time, we do not expect Martha to have all these appointments scheduled by her next visit. However, the 2022 updated CDC recommendations make clear that that chronic pain is best managed through an intense multimodal approach, and establishing care with proper specialists is essential.¹ See more detail in our previous analysis on non-opioids for subacute or chronic pain.

We need to review Martha’s prescription drug monitoring program (PDMP) to track her prior prescriptions, especially as she has recently moved. PDMPs vary state by state and are designed to help healthcare providers identify and prevent prescription drug misuse, abuse, and diversion. Very similar to the 2016 guidelines,² the CDC continues to recommend that PDMP data be reviewed prior to every opioid prescription for acute, subacute, or chronic pain and again with each visit. At a minimum, PDMP data should be reviewed every 4 months for those individuals receiving long-term opioid therapy.

At Martha’s initial visit, there was no indication that she was lying about her current medication regimen. After checking the PDMP, we see that everything is accurate and her last prescriptions for oxycodone/acetaminophen (x 180) and cyclobenzaprine (x 30) were picked up 25 days ago. This information can now be taken in the context of the previously gathered clinical information, including Martha’s history, physical findings, and relevant testing, to help communicate with and protect us both. More in our prior analysis on PDMPs.

Martha’s initial complaint to you was that her pain has been slowly progressive; however, further assessment of Martha’s PDMP shows little alteration in her regimen over the past year. As this is our first time meeting Martha, we have an excellent opportunity to see her as both a “new patient” and a “legacy patient.”

Herein lies the beauty in the art of pain medicine and your responsibility in taking Martha’s entire case (as a chronic opioid patient and new patient to your clinic) into account. Many of the 2022 CDC guideline recommendations have pitfalls and the potential for misapplication, but if utilized properly, they can serve as a guide for establishing proper care with Martha and other patients.¹

One of these applications comes in the form of Morphine Equivalent Daily Dosing (MEDD). Inputting her MEDD in an opioid conversion calculator, you calculate her MME to be 90 mg/day. The 2022 CDC recommendations take a more reasonable approach to MEDD use and risk. The updated guideline places caution on increasing and continuing total opioid dosage at more than 50 MME/day due to risk, instead of drawing a hard line on the exact number.¹

A transition to morphine sulfate 15 mg BID scheduled plus oxycodone/acetaminophen 5/325 TID PRN for breakthrough pain can help reduce her total number of pills in half and provide a trial of decreased MME (90 MME to 45 MME). In accordance with the 2022 CDC opioid prescribing guideline, extended-release/long-acting opioids should be reserved for severe, continuous pain, and for those receiving certain dosages of immediate-release opioids (eg, 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic dosages of other opioids) for at least 1 week. The Recommendation Category was decreased from A to B on this subject and allows clinicians more flexibility to make an individual assessment in the patient’s best interest instead of providing a blanket approach.¹

The 2022 guideline loosely recommends that clinicians continue to regularly reassess patients known to practice with minor changes in regimen at least every 3 months.¹ However, since we are providing dose titrations and Martha is new to our practice, we ask for a sooner follow-up visit to closely monitor her progress.

Three Weeks Later

Martha returns to the clinic 3 weeks later. She is complaining of worsening intensity and frequency of low back pain. She has been compliant with her new regimen but states that the pain has increased to a point that it now affects her ability to perform daily activities and sleep. She denies any red flags such as saddle anesthesia, new weakness, or changes in bowel/bladder. She has since been let go by her new job for calling out sick too often due to the pain. She is requesting an increase in medication as she has exceeded her PRN dose for the month.

Q: You notice that Martha becomes tearful and is difficult to redirect during your conversation. Your clinic is now running behind schedule. Are there any specific questions you would like to ask to streamline the conversation?

Unfortunately, these can be exceedingly difficult conversations to manage. It is important to listen attentively to what Martha is saying, but also be able to guide the discussion toward high-yield topics. We recommend the utilization of motivational interviewing techniques.

• respective treatment goals
• the source of pain
• common side effects from medications
• risk of overdose with medications

We need to consider our current treatment options and whether opioid treatment continues to meet Martha’s intended goals. As noted, Martha has a history of depression and anxiety and is potentially at an increased risk for opioid use disorder (OUD). Optimizing psychological treatment may be essential prior to the alteration of any pain medicine. Although awkward for many young physicians, we need to discuss changes in social behavior with the patient. For instance, asking her if there have there been any changes in her drug or alcohol consumption?

One significant change in the 2022 guidelines is the recommendation to use urine drug testing as a tool for assessing a patient’s adherence to prescribed medications and to monitor for other substances that may increase the risk of overdose.¹ Ordering a urine screen is strongly encouraged at this time.

Q: What treatment options can we offer to Martha at this time?

We currently have several options. We can increase Martha back to her previous medication dose, or we can try something new. It is important to note that Martha’s pain was never adequately controlled on the previous dose, and she was noting some associated side effects of the medication. At this point, we need to consider treatment failure, and in accordance with the 2022 updated guidelines, avoid dosage increases if possible.¹

Four Weeks Later

Martha returns to the clinic for her next follow-up. She reports significant improvement in pain symptoms with the completion of diclofenac and the start of duloxetine. She has restarted physical therapy as well as psychotherapy and has become more active. She reports overall improvement in insomnia and mood. She is compliant with her morphine sulfate 15 mg BID scheduled and only taking oxycodone/acetaminophen 5/325 one to two times per day max. She is interested in proceeding with repeat SI corticosteroid injections and discontinuing all opioid medications as soon as possible.

One of the most significant changes to the guidelines plays a role here. The 2016 guidelines were vague and nonspecific. They did not include a discussion on abrupt discontinuation. Following the updated guidelines, we should place a larger emphasis on an individual taper schedule with Martha. We should specifically warn against abrupt discontinuation. We should start with a slow and gradual schedule to minimize potential physical and psychological harm.

Overall, Martha’s case provides an excellent example of how to manage opioid medications in a legacy type of patient under the updated 2022 CDC guideline on prescribing opioids for pain.¹ These cases are often difficult and possess several factors. Not all legacy cases contain elements of opioid use disorder, opioid treatment failure, and the need for tapering. However, by breaking down Martha’s case, we can appreciate the CDC’s emphasis on the importance of safe and responsible opioid prescribing, while also recognizing the need for individualized treatment plans and incorporating new evidence and feedback from stakeholders. (See our separate case on first-time opioid therapy.)