Strategies for Managing Opioid Risk in Chronic Pain Patients

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 this interview from the recent Psych Congress 2021 meeting in San Antonio, Dr Podesta shares tips and strategies she recommends for managing risk around opioid use in chronic pain patients.

Read the transcript:

Dr Arwen Podesta: For those that suffer from both chronic pain and the potential of substance use disorder, particularly opioid use disorder, opioid addiction, you can do a lot of risk stratifying to understand clinically whether or not the patient might be a risk for developing chronic addiction or chronic substance use. Some of those things include an excellent clinical history, which, all great clinicians, those that come to Psych Congress, you’re going to have a good clinical history.

Ask about alcohol use disorder in the family and in the individual. Ask about psychiatric issues. Ask about other substance use disorders in the family. Ask about trauma, ask about current medical issues and other things that might put someone more at risk for needing or wanting something that gives them a dopamine hit, and therefore, they might have clinical evidence to have a predilection for addiction.

There’s a lot that you can do with certain blood work, with certain labs, certain genetic work as well. That’s a little more nuanced, but it’s still a piece of the puzzle. Also, if you have someone that does have a substance use disorder and they do need to be on pain medication, then just having a higher level of accountability.

Urine drug testing—appropriate, and readable, and understandable, precise urine drug testing is superior to a screen. Family involvement, maybe some lockboxes or locked cabinets where family members or clinicians can help take the patient’s medication and store it away. More frequent prescriptions, or work with a pharmacist that might be someone that you work with, and see if you can write for a 30-day supply of something, but then have them only dispense 7 days, because there’s a key where there’s a copay every time they do a refill.

These are all these little tricks for a higher level of accountability, and also, don’t forget dealing with mental health. That might include therapeutic relationships, groups, and individual treatment, and peer support.