Commentary: Considerations When Prescribing Opioids for Noncancer Pain

The initial assessment in managing patients with chronic noncancer pain should involve establishing the diagnosis, medical necessity, and treatment goals, state the authors of a commentary from the September 2013 edition of the U.S. Agency for Healthcare Research and Quality’s online case study review, WebM&M. In the spotlight case, a 42-year-old man with a history of asthma and chronic lower back pain was admitted to the hospital with community-acquired pneumonia and an asthma exacerbation. Although his primary care provider had prescribed him high doses of long-acting morphine, oxycodone, and gabapentin for his lower back pain, he admitted to selling his prescribed opiates and buying diazepam and methadone on the street because he felt they could better control his pain. After consulting the hospital’s pain service, physicians switched his medications to methadone, hydromorphone, clonazepam, and venlafaxine and discharged him with a scheduled follow-up appointment with his primary care provider that was to occur in 10 days. Five days after discharge, the patient was found unresponsive in a subway station and later died from what was determined to be an unintentional opiate/benzodiazepine overdose. Although it is unclear from the case details whether the patient's death could have been prevented, the authors note that the scenario illustrates some of the risks inherent in opioid prescribing.