How to tell a patient you will not refill an opioid prescription:
A case study

By the Texas Pain Foundation

Scenario:

Patient T is a 45-year-old male with a history of lower back pain who has been treated for the past three years by a pain management physician. He presents to a primary care physician for a refill of his opioid medications. For the past two years, he has been on a stable dose of hydrocodone and extended-release morphine. When asked why he is no longer receiving his opioid prescriptions from his pain management physician, the patient replies that this physician is no longer willing to prescribe opioids for him.

Upon reviewing his past treatments prior to chronic opioid therapy, it is determined that he underwent physical therapy of unknown type in the remote past. However, he has not tried multidisciplinary rehabilitation, tai chi, yoga, walking programs, acupuncture, mindfulness-based stress reduction, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation. As such, the primary care physician decides this is a good opportunity to discuss changes in the treatment plans for managing the patient’s chronic pain. The physician explains to the patient there are new treatment guidelines recently published by the American College of Physicians and the Centers for Disease Control that both recommend non-pharmaceutical and non-opioid therapy as the preferred treatment for chronic pain.

The physician then asks if the patient is having any opioid withdrawal symptoms. The patient states that he is having rhinorrhea, diarrhea, piloerection, and increased pain. The physician reassures the patient that increased pain is normal when going through opioid withdrawal and that this pain will improve as his withdrawal symptoms improve. In the meantime, the physician tells the patient that she will treat his diarrhea and other withdrawal symptoms with non-controlled medications, and she reassures the patient that withdrawal symptoms are not life-threatening. The physician then discusses the concept of opioid-induced hyperalgesia. In this condition, opioids lead to a paradoxical increase in perceived pain after prolonged exposure. In these patients, cessation of opioid therapy leads to decreased overall pain after withdrawal symptoms cease. As such, the physician informs the patient that she will not be refilling his opioid prescriptions today.

The patient is upset when he learns he will not receive an opioid prescription and states that opioids are the only thing that works for his pain. When the physician asks how they work, the patient states that opioids significantly reduced his pain. The physician then asks about his physical and emotional function. The patient responds that he spends 80 percent of the day sedentary watching TV or lying in bed and that he does not work. Emotionally he denies anxiety or depression but reports very little interaction with his spouse or children and that he is becoming emotionally withdrawn because of his pain. The physician then explains to the patient that although opioids may be reducing his pain, they are not increasing his physical or psychosocial function. Improvements in both perceived pain and physical function are absolutely essential for continued opioid therapy. Pain reduction alone is not an indication to continue opioid therapy.

The patient becomes increasingly agitated and the physician offers him medication to treat the withdrawal symptoms and other conservative treatments mentioned above. Realizing that the patient appears to be hyper focused on opioids and not open to alternative treatments, the physician considers whether the patient may have an undiagnosed substance use disorder and considers referring him to an addiction specialist.

After the physician spends time counseling and reassuring the patient, he remains convinced that opioids are the only treatment that works for him. The physician states that she respects the patient’s point of view but that she does not agree. The physician states that if the patient wants to continue with the new treatment plan, then they can continue talking. Otherwise, the patient can consult with another physician for a second opinion.

Takeaways

• New CDC and ACP guidelines recommend non-pharmaceutical and non-opioid therapy as first-line treatments for chronic pain.
• Opioid withdrawal should be treated, but this does not necessarily require refilling an opioid prescription.
• Opioid withdrawal is not life threatening in the absence of severe cardiovascular disease.
• Patients have the choice to accept new treatment plans or to find a new physician.
• Physicians should NOT feel pressured to refill opioid prescriptions.
• Patients who are hyper-focused on obtaining prescriptions for opioids and are not open to new treatment plans may have a substance use disorder. This should prompt the physician to consider a referral to an addiction medicine specialist.

Reasons a pain management physician would not refill

• The physician changed their treatment philosophy to be in compliance with evidence-based guidelines.
• The patient displayed evidence of opioid-induced hyperalgesia.
• The patient failed to demonstrate a functional improvement with opioid therapy.
• The patient had a nonfatal opioid overdose. This is a contraindication to future opioid prescriptions.
• The patient violated the Pain Management Agreement, which is an agreement between the doctor and patient for treatment using chronic opioid therapy as required by Texas Medical Board. Violations may include:
• Utilizing the Texas Prescription Monitoring Program, PMP Aware, the patient was found to be obtaining controlled substances from multiple physicians.
• Patient had self escalated the medication and ran out early. This is a risk factor for accidental overdose and substance use disorders.
• Patient reported lost or stolen medication. This can be associated with a substance use disorder or criminal diversion of controlled substances.
• Patient had aberrant urine drug tests results, meaning non-prescribed licit or illicit drugs were found in the urine or prescribed drugs were not in the urine.

The Texas Pain Foundation was established in 2011 to advance the art and science of pain medicine. Visit www.texaspainfoundation.org.