If the dose of narcotic prescribed was excessive or the indication inappropriate, for example for fibromyalgia, a plan for reduction or discontinuation should be discussed with the patient.
In the case described above, I would prescribe the hydrocodone for now. The dose is not excessive, the patient has documented pathology, there is no evidence of abuse, and I will be seeing the patient regularly to follow his PMR. However, I would suggest to the patient that we should gradually reduce the dose of opioids. An unanswered question is what will happen when the patient’s PMR has resolved, he is off steroids, and he no longer needs a rheumatologist.
As a rheumatologist, you have the option, but not the obligation, to take over the opioid management that you did not initiate with the patient. Most people are now very aware of the societal problem of narcotic overuse, dependence and overdose, and of the restrictions placed on medical professionals regarding use of narcotics. It is usually possible to discuss these issues with patients in a nonjudgmental and non-argumentative fashion.
Edward P. Rose, MD, is a rheumatologist in solo practice in Belleville, Ill. He is a member of the ACR Committee on Ethics. He can be reached via email.
Acknowledgment: The author acknowledges and thanks Dr. Jane Kang for her review of and advice on this article.
References
- Dowell D, Haegerich TM, Chou R. CDC’s guideline for prescribing opioids for chronic pain—United States 2016. MMWR. 2016 Mar 18;65(1):1–49.
- European Pain Federation position paper on appropriate opioid use in chronic pain management. Eur J Pain. 2017 Jan;21(1):3–19.
- Frank JW, et al. Patient outcomes in dose reduction of discontinuation of long-term opioid therapy. Ann Int Med. 2017 Aug 1;267(3):181–191.
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