Controlled Substance Agreements for Opioids in a Primary Care Practice

Abstract

BackgroundOpioids are widely prescribed for chronic non cancer pain (CNCP). Controlled substance agreements (CSAs) are intended to increase adherence and mitigate risk with opioid prescribing. We evaluated the demographic characteristics of and opioid dosing for patients with CNCP enrolled in CSAs in a primary care practice.MethodsWe conducted a retrospective cohort study of 1066 patients enrolled in CSAs between May 9, 2013 and August 15, 2016 for CNCP in a Midwest primary care practice.ResultsPatients were prescribed an average of 40.8 (SD ± 57.0) morphine milligram equivalents per day (MME/day), and 21.5% of patients were receiving ≥50 MME/day and 9.7% were receiving ≥90 MME/day. Patients who were younger in age (≥ 65 vs. < 65 years, P < 0.0001), male gender (P = 0.0001), and used tobacco (P = 0.0002) received significantly higher MME/day. Patients with more co-morbidities (Charlson Comorbidity Index, CCI) received higher MME/day (CCI > 3 vs. CCI ≤ 3, P = 0.03), and reported higher average pain (CCI > 3 mean 5.8 [SD ± 2.1] vs. CCI ≤ 3 mean 5.3 [SD ± 2.0], P = 0.0011). Patients on an identified tapering plan (6.9%) had higher MME/day than patients not on a tapering plan (P = 0.0002).ConclusionsCSAs present an opportunity to engage patients taking higher doses of opioids in discussions about opioid safety, appropriate dosing and tapering. CSAs could be leveraged to develop a population health management approach to the care of patients with CNCP.

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“…Although the use and misuse of prescription opioids and opioid-related mortality in European countries are rather low, the number of opioid prescriptions has increased over the last decade (25). Despite recommendations and guidelines to avoid doses above 90 MME, a significant proportion of chronic noncancer pain patients still receive doses ≥90 MME (20,26,27). Additionally, questions are raised about the long term effects from other (nonaddictive) painkillers stronger than paracetamol and/or NSAIDs (28).…”

Determining the Minimal Clinical Important Difference for Medication Quantification Scale III and Morphine Milligram Equivalents in Patients with Failed Back Surgery Syndrome

“…Due to this epidemic, many researchers only focus on opioids instead of taking neuropathic pain medication, muscle relaxants, and other categories into account. Moreover, for chronic noncancer pain, recommendations and guidelines strive towards avoiding doses above 90 MME [ 26 , 27 , 28 ], wherefore a clinically important change in MME might be very relevant for clinicians that mainly aim to focus on opioid reduction.…”

10 kHz SCS therapy for chronic pain, effects on opioid usage: Post hoc analysis of data from two prospective studies

“…Despite clear guidance on maximum doses of opioids and the rationale for high-dose opioids becoming weaker, patients continue to rely on doses > 90 MME for pain management. A recent retrospective analysis of 1,066 primary health care records of patients prescribed opioids for chronic non-cancer pain, 9.7% were receiving ≥90 MME 59 . In 2012, the CDC reported that 10% of patients on prescription opioids were receiving a high-dose (>100 MME) from one doctor, and of those who overdosed, 40% were also prescribed their pain relief from a single doctor 29 .…”