Good care concerning opioid prescribing (there is no difference for us whether it’s oxycodone, hydrocodone, morphine, etc) for non-cancer chronic pain includes a thorough history (pain generation, intensity and characteristics, things that exacerbate or improve, timing, previous treatments tried, past medical and surgical history, social history, and review of symptoms, etc.) and physical exam. The physical exam is an important aspect, as it can provide information about other potential undiagnosed comorbidities (obstructive sleep apnea, heart failure, etc.) that could affect a given patient’s response to opioids. Also, it significantly adds information that may help treatment decisions; allodynia and hyperpathia suggesting neuropathic pain; motor weakness and muscle atrophy suggestive of a pinched nerve root; and also information that may raise some concern for drug seeking such as exaggerated pain behaviors, give away weakness, non-concordant responses to various tests. Review of additional diagnostic information is also essential (labs, radiographic images, etc.). Non-opioid strategies should be employed first, or at the very least, documented in detail before consideration of opioid therapy. If considered a good candidate, a risk stratification tool should be performed (ORT – opioid risk tool is a set of questions that indicates whether a patient may have a predisposition towards misuse, abuse or addiction. ORT is what I use, but there are others). I would also have a long discussion about risk and benefits, review the state drug database looking for concerning behaviors (multiple prescribers, pharmacies, etc.), assess a urine drug screen and then sign a contract with the patient. It is difficult to adequately define what the bare minimum of a physical exam is. I would say at least a focused exam of the painful area with mention of gross visual inspection, range of motion, tenderness to touch, and any special relevant maneuvers (straight leg raise suggestive of nerve entrapment). It is a breach of the standard of care to fail to adequately perform a physical in advance of prescribing opioids to a new patient. In my clinic, an 18 year old male better have some overwhelming pain condition to justify chronic opioid therapy – it is very rare. As far as determining if a patient is there to obtain drugs for legitimate medical concerns or not, it is often difficult and really an effort at the best informed decision based on the data present. But it is a combination of the data based on the history, risk profile, physical findings, imagining, etc. The reality is that pain medicine is moving away from chronic opioid therapy in general as we have growing evidence that people on relatively high doses of opioid are self-selective based on psychological comorbidities and that when used for common conditions like back pain, they do worse over time. Sometimes it is the only thing that can provide one with a reasonable quality of life, but it should be used after everything else has failed and the patient is appropriately monitored, as even the most conservative and vigilant prescribers of opioids get duped. It’s just the reality of the current state of the art.
