Navigating the Opioid Crisis: A Primary Care Perspective

Kenneth W. Lin, MD, MPH; Charles P. Vega, MD


August 02, 2016

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Charles P. Vega, MD: Hello, and welcome to Critical Issues in Pain Management. I'm Chuck Vega, clinical professor of family medicine at the University of California, Irvine.

I'm delighted today to be joined by Dr Kenneth Lin, codirector of Patients, Populations, and Policy at Georgetown University Medical Center's Department of Family Medicine. Kenny, thanks very much for joining me.

Today we're going to be talking about pain. Anyone who sees patients understands what a big problem pain is. To provide a little bit of context into the issue of chronic pain in the United States, there was a very broad survey[1] that found that 30% of US adults, or roughly 1 in 3, experienced some form of pain in the past 6 months. One half of those patients with pain experienced it daily, and one third of them rated their pain as severe. Low back pain and osteoarthritis were the most common forms of chronic pain.

These patients want to get better, so they go see their healthcare professional. Among visits specifically for pain, 20% will result in a prescription for an opioid medication. The rates of opioid prescribing rose significantly between 2000 and 2010,[2] but that's leveled off a bit in the past few years. Why?

A primary issue is safety. We know that opioids are associated with several negative consequences, such as misuse, addiction, and overdose. Between 1999 and 2014, there were 165,000 deaths in the United States due to prescription opioid overdose.[3] In 2011 alone, there were over 400,000 emergency department visits for prescription opioid overdose.

But it's not just the issue of overdose and safety; there's also some question about the efficacy of these medications. A recent quality review[4] of the management of low back pain found that the average improvement with opioid medications was 8-12 points on a 100-point pain scale. That's only very marginally clinically significant. The review also noted that in one half of the research studies that examined opioids, the dropout rate in the opioid treatment arms was at least 50%, owing to lack of efficacy or side effects.

Given that background, Kenny, I'm going to throw you a very difficult question: If not opioids, what do we do for patients with pain—acute pain or chronic pain? These are very difficult conditions to treat. What are your thoughts?

Kenneth W. Lin, MD, MPH: I should say first that I think there are some patients who ultimately do need opioids, for whom there aren't any other options. That being said, we are probably prescribing too much or are too willing to prescribe them long-term—more than 3-7 days for acute pain. Most of the time, when patients come to us, they've already tried acetaminophen or nonsteroidal anti-inflammatory medications, although sometimes they're doing so suboptimally by not using round-the-clock dosing or taking them at inadequate doses.

One thing that the Centers for Disease Control and Prevention (CDC) guideline[5] points to is that we underuse, perhaps, such things as physical therapy or even acupuncture, which can be shown to improve at least short-term outcomes in back pain and have evidence at least as strong as that for opioids—not that opioids have very strong supporting evidence themselves, either. The CDC guideline was a good attempt to try to consolidate all the information we do have. It was done with a systematic review. The trouble is that most of these opioid studies only follow people up to maybe 2 or 3 months. After that, we're really not sure what happens. So, many of the recommendations were based on expert opinion and/or common sense.

In terms of answering the first question that you asked, there are some other options that we should try initially. After that point, you then have to look at the risks and benefits of opioids.

Setting Reasonable Patient Expectations

Dr Vega: Thanks very much for bringing up that CDC recommendation, because it's been pretty controversial, with a severe limitation on the suggested duration for acute prescriptions of 3-7 days maximum. That got a lot of attention and headlines, and how it's applied will vary among different practices and certainly from patient to patient.

In my experience, all treatments for such conditions as chronic low back pain and severe osteoarthritis are fairly limited. Therefore, I have to think about "doing no harm" as a good rule to follow. Before I prescribe opioids, I of course want to exhaust all those other options. Then I agree with the CDC's recommendation of really discussing the goals of therapy before a prescription is written.

Patients understand that this should not be a chronic therapy. It's meant to relieve pain for a limited amount of time, because the research shows that opioids don't necessarily improve function among patients with chronic pain. So I think those are solid recommendations. And I agree that you should try every alternative treatment you can because they tend to be safer, if nothing else.

Dr Lin: The distinction between acute and chronic pain relief is really important to me. For acute pain, I think it is a reasonable expectation to say that if you take the opioids your pain will be mostly, if not entirely, relieved. But for chronic pain, I think you have to warn patients that it's very unlikely that they'll receive 90%-100% relief of their pain. The idea is to improve their function so that they can perhaps participate in other things, such as exercise, that also will help relieve their pain. But it's not going to be a magic bullet that will completely take pain away.

Dr Vega: Setting those expectations and then revisiting them, and not just prolonging therapy month after month, is critical, because that's where that treatment inertia can be a real problem and patients can get into trouble with opioid addiction and misuse.

Harm Reduction and Due Diligence

Dr Vega: Do you have any strategies in terms of reducing the harm associated with opioids with those particular adverse events?

Dr Lin: With any patient whom you are considering for long-term opioid therapy, there are a couple of major things to do before you start that.

First, you have to get a good background on the patient's pain condition and how it came about, possibly using their past medical records. If your state has a prescription-drug monitoring program, you should run the patient through it and see whether there are any red flags that pop up.

Second, I have any patient who's going to take opioids for longer than a few weeks sign a pain contract, which basically delineates what our expectations are and what they need to agree to. For example, this will say that they can only get the pain prescriptions from me; they can't go doctor-shopping and find pain medications at other practices or emergency rooms (ERs); and periodically, we may choose to submit them to urine drug tests to ensure that there aren't any other substances in their blood that shouldn't be there or, conversely, that we don't see evidence of their pain medication, which would indicate that they're doing something else with it.

Those are the first things I do. They're not foolproof. I've certainly still been burned from time to time, but I think they do at least weed out people who would not be suitable for long-term opioid therapy.

Dr Vega: I totally agree. The prescription drug monitoring programs have been very helpful to me in identifying, not a majority, but certainly some patients who have been using opioids and other substances, such as benzodiazepines, from other healthcare centers. That indicates a high-risk patient for me right away. We need to have a serious talk with them about whether we're going to continue any kind of pain management therapy at all, particularly if they're breaking the rules of their pain management contracts.

Incorporating Naloxone Prescriptions

Dr Vega: The other interesting thing that came out of the CDC recommendations was a broad endorsement of prescribing naloxone for patients at high risk for overdose. This is a harm-reduction strategy that, although not ideal, is actually quite realistic, given that most patients who get into situations where they can potentially overdose on opioids may be in their home or out in the community. Therefore, having naloxone handy can help save lives. The CDC specifically recommends it for patients with a history of substance abuse or concomitant use of benzodiazepines. Those patients are really at a high risk for overdose.

The other key is that patients, and their loved ones who might be helping care for them, need to understand that they're not just supposed to administer naloxone and forget about it. They're supposed to call 911, give the naloxone, and then get the patient to a health center as quickly as possible so they can receive emergency care.

Dr Lin: I've been persuaded to start prescribing naloxone for those very same patients you just talked about. At the time the CDC guideline was released, there actually weren't any studies in primary care settings of distributing naloxone. The studies that have been done were in community-based settings where you had so-called "Good Samaritans," or possibly relatives or friends of people who were using chronic opioids, who were trained in how to use naloxone. Those studies showed successful outcomes.

The question was, does coprescribing naloxone actually work? There was an interesting study[6] published in late June in the Annals of Internal Medicine about some safety-net primary care clinics in San Francisco whose clinicians have been encouraged over the past few years to prescribe naloxone. The study showed that the people who received naloxone had a lower rate of ER visits and opioid overdose than the groups that didn't get it, and those receiving naloxone were thought to be the more high risk. Even though this wasn't a randomized study, it does strongly suggest that this strategy works in the right populations.

Dr Vega: It's hard to do research in this population overall, so I think that's encouraging. I believe that in Baltimore, near your hometown, there's a very broad program for offering naloxone through community centers. It's fairly readily available, which indicates that they're really embracing harm reduction in a broad population sense there, and using it to stem what really is a public health crisis.

Dr Lin: Absolutely. Baltimore's Health Commissioner is actually an ER physician who used to work in Washington, DC. I think she was very impressed by all the overdoses that she saw when she was working in the ER setting, and so has been very aggressive and enthusiastic about promoting naloxone's availability for at-risk patients.

Parting Advice

Dr Vega: In conclusion, make sure that you try alternatives before prescribing opioids and, if you must use opioids, keep the duration of treatment short with the lowest dose possible.

One thing I also neglected to mention was avoiding the use of long-acting agents in favor of short-acting agents. Then, for those minority of patients who need more chronic opioid therapy, we recommend prescription drug management programs, urine toxicology testing, pain contracts, and reviewing their pain and function over time so that they can eventually get off the therapy as quickly as possible. Those are the basics to apply in clinical practice.

I see a lot of variability when I'm actually with my patients regarding how to apply these guidelines, so I'm curious whether you have any other thoughts or opinions.

Dr Lin: Especially if you're in a fairly large practice, it's important that the clinicians sit down together and establish the rules that everyone will follow. You don't want to be out of sync with one of your colleagues by prescribing opioids to a patient to whom they don't want you prescribing, or vice versa.

My practice only has 6 or 7 clinicians, but we took some time to sit down and say, these are our policies, everybody's going to do this, and that way we'll send out the same message to patients regardless of whom they happen to see at a particular visit.

Dr Vega: I think we discussed some commonsense items here today, but at the same time guidelines are guidelines. They don't necessarily mandate exactly what you should do for each individual patient. But I think these are strong recommendations that make a lot of sense clinically and should help people to actually live longer and better. I'm excited to try to use them in my practice, and I really appreciate your insights here today.

Dr Lin: Thanks for having me today.

Dr Vega: We'll see you next time on Critical Issues.


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