COMMENTARY

Let's Face It--Some of Our Patients Need to Be on Long-term Opioids

Kenneth W. Lin, MD, MPH

Disclosures

February 04, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Hello, everyone. I'm Dr Kenny Lin, a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.

According to a National Institutes of Health–sponsored workshop,[1] an estimated 25 million Americans experience moderate to severe chronic pain, and 5-8 million of them use opioids for long-term pain management. Although it is now widely recognized that excessive opioid prescribing has contributed to an epidemic of opioid use disorder and overdoses, the adoption of inflexible dosing limits or "no opioid" policies by many physicians and pharmacy benefit managers has also caused substantial harm.

Last November, the American Medical Association's House of Delegates adopted several resolutions that advocated against misapplication of the 2016 CDC guideline on opioids for chronic pain. An international group of pain experts[2] recently called for "an urgent review of mandated opioid tapering policies for outpatients at every level of health care ... to minimize the iatrogenic harm that ensues from aggressive opioid tapering policies."

Individual clinicians will ultimately decide for themselves whether or not, and to what degree, to continue to prescribe opioids to existing patients with chronic non-cancer pain. Although forced tapering and patient abandonment is unethical, a case series[3] published in the Journal of Family Practice illustrated that voluntary tapering is feasible for many patients on chronic opioid therapy, as long as referral to a pain center is available for patients who decline. Stanford University School of Medicine offers a free continuing medical education course on best practices for chronic opioid tapering in partnership with patients.

My clinical experience and a recent systematic review[4] convince me that selected patients with chronic non-cancer pain receive more benefit than harm on opioid therapy. Tools that I use routinely to reduce the risk for opioid misuse or diversion include risk assessments, controlled substances agreements, prescription drug monitoring programs (PDMPs), and frequent follow-up visits. A helpful FPM article[5] provides additional strategies and protocols that can be utilized in primary care practices.

An ongoing challenge in my practice is inheriting patients on chronic opioid therapy whose previous physicians have retired or stopped prescribing. If this applies to you, please do your patients a favor and facilitate their care transitions by documenting their chronic pain diagnoses, comorbid physical and mental health conditions, acute pain triggers, other pharmacologic and nonpharmacologic interventions that have or have not helped, and the rationale for past increases or decreases in opioid dosing.

In their draft report on pain management best practices, an interagency task force convened by the Department of Health and Human Services recommends that care for these patients be balanced, individualized, and include multiple modalities such as interventional procedures, physical therapy, integrative medicine, and behavioral health if indicated. It recommends that Medicare, Medicaid, and private insurers pay for effective nonpharmacologic pain therapies and reimburse primary care clinicians adequately for the time and resources required to manage patients with chronic pain.

The draft report reiterates the limitations of the CDC opioid prescribing guideline and states that legislation or payer requirements for a one-size-fits-all approach to acute or chronic pain are inappropriate and potentially harmful. For example, although care teams should access PDMP data periodically, making it mandatory to check the PDMP prior to every single interaction involving an opioid prescription creates unnecessary burdens for practices.

Finally, the report discourages healthcare professionals and the general public from stigmatizing patients with chronic pain "as people seeking medications to misuse."

While much remains to be done, I am optimistic that we are turning a corner in the treatment of persons with chronic pain. With prudent prescribing practices and multidisciplinary collaboration, it is possible for family physicians to relieve suffering without worsening the opioid epidemic.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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