Residency · Residency · Physical Medicine Rehabilitation

Opioid Stewardship in Rehabilitation Medicine

Overview

Opioid epidemic has had profound impact on rehabilitation populations. PM&R physicians frequently manage patients with chronic pain on long-term opioid therapy. Rehabilitation patients are at unique risk: chronic pain conditions, functional impairment, mood disorders, polypharmacy. Physiatrist role: risk assessment, safe prescribing, multimodal analgesia, opioid tapering, and care coordination. Balance between undertreating pain (functional limitation) and overprescribing (dependence, adverse effects).

Scope of the Problem

Over 10 million Americans misuse prescription opioids annually. Opioid overdose deaths exceed 80,000/year in the US. Chronic opioid therapy for non-cancer pain has limited evidence for long-term functional improvement. SCI, TBI, and stroke populations have elevated rates of chronic pain and opioid use. Opioids impair neuroplasticity and rehabilitation participation.

Risk Assessment

Pre-Prescribing Evaluation

Comprehensive pain assessment (location, quality, intensity, functional impact). Prior opioid use history and response. History of substance use disorder (personal and family). Psychiatric comorbidities (depression, anxiety, PTSD). Sleep disorders (opioids worsen sleep apnea - especially relevant in SCI, TBI). Concurrent sedating medications.

Risk Stratification Tools

Opioid Risk Tool (ORT): brief, validated screening questionnaire. SOAPP-R (Screener and Opioid Assessment for Patients with Pain - Revised): 24-item self-report. DIRE (Diagnosis, Intractability, Risk, Efficacy): clinician-rated assessment. No tool is perfectly predictive - clinical judgment remains essential.

Risk Categories

Low risk: no personal or family history of SUD, no psychiatric comorbidity. Moderate risk: family history of SUD, stable psychiatric condition. High risk: personal history of SUD, active psychiatric instability, concurrent benzodiazepine use.

<image>Opioid risk assessment algorithm for rehabilitation patients including screening tools and risk categories</image>

Evidence-Based Opioid Prescribing Guidelines

CDC Clinical Practice Guideline (2022 Update)

Non-opioid therapies are preferred for chronic pain. When opioids are used, combine with non-pharmacologic and non-opioid pharmacologic therapies. Start with immediate-release opioids at lowest effective dose. Prescribe ≤ 3-day supply for acute pain (rarely > 7 days).

Avoid concurrent benzodiazepines and opioids. Re-evaluate benefits and risks within 1-4 weeks of starting opioids. For chronic therapy: re-evaluate at least every 3 months. Check PDMP (prescription drug monitoring program) at every visit. Consider offering naloxone to patients at risk for overdose.

Morphine Milligram Equivalents (MME)

Standardized metric for comparing opioid doses. Key thresholds: < 50 MME/day: lower risk. 50-90 MME/day: increasing risk, reassess regularly.

≥ 90 MME/day: high risk, avoid or carefully justify. Conversion examples: Hydrocodone: 1:1 (MME = mg). Oxycodone: 1.5:1 (10 mg oxycodone = 15 MME).

Hydromorphone: 4:1 (2 mg = 8 MME). Morphine: 1:1. Methadone: complex, dose-dependent conversion (5-12:1). Fentanyl patch: 25 mcg/hr ≈ 60 MME/day.

Monitoring During Opioid Therapy

PDMP check at every visit (mandatory in most states). Urine drug testing: baseline and periodic (random). Confirm presence of prescribed opioid. Screen for non-prescribed substances.

Understand limitations (immunoassay vs. confirmatory testing). Functional outcome tracking (not just pain scores). Treatment agreements/informed consent documentation. Naloxone co-prescription for patients on ≥ 50 MME/day or with risk factors.

Multimodal Analgesia Strategies

Non-Pharmacologic Approaches

Physical therapy: therapeutic exercise, manual therapy, modalities. Cognitive-behavioral therapy: pain coping skills, catastrophizing reduction. Mindfulness-based stress reduction: meditation, body scan techniques. Acupuncture: moderate evidence for chronic musculoskeletal pain.

Yoga and tai chi: evidence for chronic low back pain, fibromyalgia. TENS: gate control mechanism, useful adjunct. Heat/cold therapy: simple, accessible, effective.

Non-Opioid Pharmacologic Options

Acetaminophen: first-line, ceiling dose 3 g/day (2 g/day in liver disease). NSAIDs: effective for inflammatory and musculoskeletal pain; GI, renal, and cardiovascular risks. Topical NSAIDs: diclofenac gel - fewer systemic effects. Gabapentinoids: pregabalin, gabapentin for neuropathic pain.

SNRIs: duloxetine (chronic musculoskeletal pain, neuropathic pain, fibromyalgia). TCAs: low-dose amitriptyline/nortriptyline for neuropathic pain and sleep. Muscle relaxants: cyclobenzaprine (short-term), tizanidine, baclofen. Topical lidocaine: 5% patches for localized pain.

Capsaicin: high-concentration (8%) patch for neuropathic pain. Ketamine: low-dose IV infusions for refractory neuropathic pain (emerging).

Interventional Approaches

Trigger point injections. Joint and bursal injections (corticosteroid, hyaluronic acid). Epidural steroid injections. Medial branch blocks and radiofrequency ablation. Peripheral nerve blocks. Spinal cord stimulation. Intrathecal drug delivery (non-opioid options: ziconotide).

<image>Multimodal analgesia pyramid showing non-pharmacologic base through interventional approaches</image>

Opioid Tapering

Indications for Tapering

Pain not improving despite opioids. Functional decline or stagnation on opioids. Side effects outweighing benefits (sedation, constipation, hypogonadism). Evidence of opioid use disorder. Patient request. Concurrent high-risk medication use (benzodiazepines). Dose ≥ 90 MME/day without clear benefit.

Tapering Principles

Individualized approach - no one-size-fits-all protocol. Shared decision-making with the patient. Gradual taper: 5-10% reduction per month for long-term users. Faster tapers (10-20% per week) possible for shorter-duration therapy.

Slower tapers better tolerated and lower dropout rates. Pause taper if withdrawal symptoms are severe. Never abruptly discontinue in chronic users (withdrawal risk).

Withdrawal Management

Symptoms: anxiety, insomnia, myalgias, diaphoresis, rhinorrhea, GI distress, tachycardia. Supportive medications: Clonidine: 0.1-0.2 mg BID for autonomic symptoms. Loperamide: for diarrhea.

Hydroxyzine or trazodone: for insomnia/anxiety. NSAIDs/acetaminophen: for myalgias. Monitor closely during first 2 weeks of each dose reduction.

Opioid-Induced Hyperalgesia

Paradoxical increase in pain sensitivity from chronic opioid use. Suspect when: increasing doses needed, diffuse pain spreading beyond original site, allodynia. Management: opioid dose reduction or rotation (counterintuitive but effective). NMDA receptor antagonists (ketamine, methadone) may help.

Opioid Use Disorder (OUD) in Rehabilitation

Recognition

DSM-5 criteria: ≥ 2 of 11 criteria in 12-month period. Key signs: loss of control over use, craving, continued use despite harm, tolerance, withdrawal. Distinguish physical dependence (expected) from OUD (behavioral pattern). SBIRT (Screening, Brief Intervention, Referral to Treatment) model.

Medication-Assisted Treatment (MAT)

Buprenorphine/naloxone (Suboxone): partial mu-agonist, can be prescribed in outpatient setting with X-waiver (now waiver requirement eliminated). Methadone: full mu-agonist, dispensed through OTPs (opioid treatment programs). Naltrexone (extended-release injection): mu-antagonist, requires full detoxification first. All three reduce mortality from OUD by 50% or more.

Naloxone (Narcan) Co-Prescription

Indicated for patients on ≥ 50 MME/day, concurrent benzodiazepines, history of overdose, or SUD risk factors. Nasal spray (4 mg) or auto-injector. Educate patient AND household members on use. Standing order available in many states.

<image>Opioid tapering protocol with timeline, dose reduction strategy, and withdrawal symptom management</image>

Special Considerations in Rehabilitation Populations

Spinal Cord Injury

High prevalence of chronic neuropathic pain. Opioids generally ineffective for central neuropathic pain. Respiratory depression risk in cervical SCI. Constipation worsens neurogenic bowel. Sedation impairs rehabilitation participation.

Traumatic Brain Injury

Opioids impair neuroplasticity and cognitive recovery. Increased fall risk with sedation. Confound neurocognitive assessment. Interaction with anti-seizure medications.

Stroke

Risk of sedation, falls, and cognitive impairment. May mask neurological changes. Consider non-opioid approaches for post-stroke pain syndromes.

Clinical Pearls

Pain intensity scores alone should never drive opioid prescribing decisions - functional outcomes matter more than pain ratings. Always check the PDMP before prescribing or refilling opioids - it takes 30 seconds and can save a life. Opioid-induced hyperalgesia should be suspected when a patient reports worsening, diffuse pain despite escalating opioid doses. In SCI patients, opioids worsen both neurogenic bowel (constipation) and respiratory function (cervical injuries) - the risk-benefit ratio is rarely favorable. Co-prescribe naloxone for any patient on ≥ 50 MME/day and document the conversation.

References

• Dowell D, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95.
• Berna C, et al. Tapering long-term opioid therapy in chronic noncancer pain. Clin J Pain. 2015;31(6):498-504.
• Clark DJ, Schumacher MA. America's opioid epidemic: supply and demand considerations. Anesth Analg. 2017;125(5):1667-1674.
• Kaye AD, et al. Prescription opioid abuse in chronic pain: an updated review of opioid abuse predictors. Curr Pain Headache Rep. 2017;21(6):25.
• Cifu DX, et al. Braddom's Physical Medicine and Rehabilitation. 6th ed. Elsevier; 2020.

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