Clinical Cases Podcast Series-FREE NO CME-Risk Management: Putting it All Together

Risk Management: Putting it All Together
Pdf Summary
This toolkit summarizes best practices for managing pain while simultaneously managing the risks of opioid therapy. Pain care is complex: opioids carry overdose mortality risk (reported roughly 0.02–0.08% among prescribed patients) and long-term harms (e.g., osteoporosis, depression, opioid-induced hyperalgesia), yet other common analgesics such as NSAIDs also have serious risks (e.g., GI-bleed mortality around 0.02%). Clinician competence is framed in three domains—knowledge, application, and documentation—applied across two interrelated tracks: pain management and risk management.<br /><br />For pain management, the document emphasizes thorough assessment of pain characteristics, function, onset, course, diagnostic workup, and targeted examination/testing. Non-opioid strategies are preferred, guided by pain phenotype (nociceptive vs centralized/neuropathic vs mixed). It reviews medication options (NSAIDs, acetaminophen, antidepressants, gabapentinoids, topical lidocaine, NMDA antagonists, muscle relaxants, cannabinoids, and selected supplements) and non-medication therapies (exercise, mindfulness, sleep hygiene, weight loss; plus professionally directed PT/OT, acupuncture, procedures, surgery, and psychological therapies such as CBT/ACT).<br /><br />Opioids may be appropriate for acute/postoperative pain, but should be limited in quantity; long-term use for chronic pain remains controversial. Opioid selection can be influenced by comorbidities (e.g., renal/hepatic disease, constipation risk) and safety profiles (e.g., buprenorphine may have less respiratory depression and lower addiction liability). Follow-up targets ~30% improvement in pain and function, with structured side-effect review and strategies for end-of-dose failure, breakthrough pain (limit short-acting doses; prefer non-opioid options), or opioid rotation. The toolkit encourages offering voluntary, patient-centered tapering to most long-term opioid patients; abrupt discontinuation is reserved for major aberrancies (e.g., forgery, diversion), with withdrawal symptom medications when needed.<br /><br />Risk management is organized into screening, stratification, mitigation, monitoring, and aberrrancy management. Key risk factors include personal/family SUD, psychiatric illness, trauma, high opioid dose, multiple prescribers/pharmacies, pulmonary disease, and benzodiazepine co-prescribing. Recommended tools include SBIRT substance screening (with AUDIT, CUDIT-R, DAST-10, Fagerström as indicated), PDMP review, definitive drug testing (GC-MS/LC-MS/MS), SOAPP-R (and alternatives), STOP-BANG, and EKGs for methadone. Mitigation includes informed consent as a communication process, controlled substance agreements, naloxone prescribing, safe storage/disposal education, MME tracking, and avoiding benzodiazepines. Monitoring includes the “Five A’s,” COMM, periodic PDMP and drug testing frequency based on risk level, and graded responses to low/intermediate/high aberrancies, prioritizing continued care and referral over dismissal.
Keywords
opioid therapy
pain management
risk mitigation
non-opioid analgesics
chronic pain
opioid tapering
substance use screening
PDMP monitoring
naloxone prescribing
multimodal therapy