Help Fight the Opioid Epidemic

Important Prescription Practice Update.

For the convenience of providers in responding to the opioid overdose epidemic—described as the worst public health crisis in the Commonwealth of Pennsylvania—Capital BlueCross makes available the following provider education resources.

Online Education from PA Department of Health

Learn how to use the Prescription Drug Monitoring Program (PDMP) to improve population health. Accreditation available.

PA Department of Health

Treating Chronic Pain

Patients with pain should receive treatment that provides the greatest benefit. Opioids are not the first-line therapy for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Evidence suggests that non-opioid treatments, including non-opioid medications and non-pharmacological therapies, can provide relief to those suffering from chronic pain, and are safer. Effective approaches to chronic pain should:

  • Use disease-specific treatments when available (e.g., triptans for migraines; gabapentin, pregabalin, or duloxetine for neuropathic pain).
  • Consider interventional therapies (e.g., corticosteroid injections) for patients who fail standard non-invasive therapies.
  • Use multimodal approaches, including interdisciplinary rehabilitation for patients who have failed standard treatments and/or have severe functional deficits or psychosocial risk factors.
  • Identify and address coexisting mental health conditions (e.g., depression, anxiety, and post-traumatic stress disorder).

Recommended Treatments for Common Chronic Pain Conditions

Recommended Treatments for Chronic Pain Conditions

The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA), have made the following recommendations for treating chronic pain from specific conditions.

Chronic Pain Type

Patient Education

Non Pharmacological Treatments

Medications

Second Line Medications /
Acute Treatments

Lower Back

Remain active and limit bed rest

  • Exercise
  • Cognitive behavioral therapy
  • Interdisciplinary rehabilitation
  • Acetaminophen
  • Non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen)
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs) (e.g., venlafaxine)
  • Tricyclic antidepressants (TCAs) (e.g., amitriptyline, desipramine, imipramine, nortriptyline)

Migraine

Avoid migraine triggers

  • Cognitive behavioral therapy
  • Relaxation
  • Biofeedback
  • Exercise therapy
  • Beta blockers (e.g., atenolol, metoprolol, propranolol)
  • TCAs (e.g., amitriptyline, desipramine, imipramine, nortriptyline)
  • Anti-seizure medications (e.g., divalproex sodium, topiramate)
  • Calcium channel blockers (e.g., verapamil, nifedipine)
  • Aspirin, acetaminophen, NSAIDs (e.g. ibuprofen) (may be combined with caffeine)
  • Anti-nausea medication (e.g. ondansetron)
  • Migraine-specific triptans (e.g., sumatriptan, frovatriptan)

Neuropathic

Address:

  • Diagnosis
  • Treatment
  • Interventional approaches (nerve blocks, ablative techniques, etc.)
  • Surgical approaches
  • TCAs (e.g., amitriptyline, desipramine, imipramine, nortriptyline)
  • SNRIs (e.g. venlafaxine)
  • Gabapentin/pregabalin
  • Topical lidocaine

Osteoarthritis

Address:

  • Diagnosis
  • Treatment
  • Exercise
  • Weight loss
  • Interventional approaches
  • Surgical approaches
  • Acetaminophen
  • Oral NSAIDs (e.g., ibuprofen)
  • Topical NSAIDs (e.g. voltaren gel)
  • Intra-articular hyaluronic acid
  • Capsaicin (limited number of intra-articular glucocorticoid injections if acetaminophen and NSAIDs are insufficient)

Fibromyalgia

Address:

  • Diagnosis
  • Treatment
  • Patient’s role in treatment
  • Low-impact aerobic exercise (e.g., brisk walking, swimming, water aerobics, or bicycling)
  • Cognitive behavioral therapy
  • Biofeedback
  • Interdisciplinary rehabilitation

FDA-approved:

  • Pregabalin
  • Duloxetine
  • Milnacipran
  • TCAs (e.g., amitriptyline, desipramine, imipramine, nortriptyline)
  • Gabapentin

Dental Prescribers

Dental prescribers often provide acute pain treatment in cases of dental emergencies or as part of routine dental care. If properly trained, dental prescribers may also be involved in the treatment of chronic facial and neuromuscular pain that may require more potent opioids. The following are clinical recommendations for prescribing opioids for acute dental pain. These recommendations are based on the Pennsylvania guidelines.1

  1. Before beginning opioid treatment:
    1. Conduct and document a medical and dental history that includes an update of all current medications, a Prescription Drug Monitoring Program (PDMP) query, and a physical examination.
    2. Talk to all other prescribers, as appropriate, for the patient.
    3. Conduct the appropriate diagnostic and imaging tests for the patient.
    4. Formulate at least a preliminary diagnosis for why the patient is having pain. 
  2. Clinicians should administer non-steroidal anti-inflammatory drugs (NSAIDs) before administering opioids (unless there are absolute contraindications to NSAIDs), as most cases of dental pain include an inflammatory component.
  3. Clinicians should consider beginning NSAIDs immediately before dental treatment and continue a scheduled dosage following the procedure.
  4. To avoid the use of opioids to treat acute pain following a procedure, clinicians should consider administering local anesthetics or regional nerve blocks to assist in pain management. 
  5. If an opioid is to be administered, the prescriber should ensure that the dose and duration of therapy only last for a short period.
    1. Access the PDMP database before prescribing opioids and act in accordance with the current Pennsylvania state laws.
    2. Document the patient’s psychiatric status, substance use history, and assess opioid misuse risk and harm.
    3. Choose the lowest potency opioid necessary to treat the patient’s pain, as long-acting or extended-release opioids are not suggested for acute pain.
    4. Check medical history and obtain a list of current medications to determine any potential interactions with other prescriptions and assess the risks involved. Some of the risks include:
      1. Individuals taking benzodiazepines, which interfere with the metabolism of some prescription opioids and increase the risk of adverse events or even death.
      2. Individuals with obstructive sleep apnea who are at an increased risk for adverse events from opioid-induced respiratory depression. 
  6. Do not prescribe extended-release opioids unless the clinician has training and experience in treating chronic facial or neuromuscular pain.
  7. Coordinate pain therapy with other clinicians before treatment if: 
    1. The patient is receiving chronic opioids as shown on their PDMP report.
    2. The patient has a history of substance use disorder.
    3. The patient is at a high risk for aberrant drug-related behavior.
  8. Coordinate pain therapy with other clinicians before treatment if: 
    1. In general, it is not proper to prescribe opioids without a face-to-face encounter and evaluation with the patient.

Proper Disposal of Controlled Substances

According to American Medical Association (AMA), 16.7 million people said they used prescription drugs for a non-medical purpose in the past year. Of that number, 70 percent said they obtained their pills—primarily opioids—from family and friends, including stealing from a home medicine cabinet.2
Proper disposal of controlled substances, like opioids, is crucial to curbing abuse.

Patients should be educated about the dangers of saving unused medications: Urge them to safely dispose of expired, unwanted, and unused medications using pharmacy and law enforcement “take back” resources whenever possible.

Access the Controlled Substance Public Disposal Locations – Search Utility for the U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Division.

Opioid Limits

1Pennsylvania Department of Health, Pennsylvania Department of Drug and Alcohol Programs, Pennsylvania Dental Association. Pennsylvania Guidelines on the Use of Opioids in Dental Practice. 2015.

2According to the American Medical Association