How Do We Get Enough Physicians to Medically Manage The Difficult (High-dose Opioid) Pain Patient?
Push for Education and Collaboration
Joseph Shurman, MD
La Jolla, California
We need to push for more education on documentation. These include: pain management agreements, urine screens, genetic testing, opioid risk scales, goals and outcomes, quarterly reviews, state monitoring systems (for example, California’s CURES), and informed consents. The Emerging Solutions in Pain Website (http://www.emergingsolutionsinpain.com) has a tool kit that can help clinicians with these issues. Also, there needs to be more emphasis on monitoring patients’ sleep, depression, driving, etc. Regarding therapy, be balanced; it’s not just about medications and interventions (explore physical therapy, water therapy, alternative techniques, etc).
Most importantly, wherever possible, physicians should use outside consultation: pain specialists, psychotherapists, orthopedists, neurologists, pharmacists, addictionists, and sleep disorder specialists (ie, using the Share the Risk model first highlighted in the October 2006 issue of Practical Pain Management).1 If you refer interventional procedures to pain specialists, you can ask them to do consults on medical management. Unfortunately, when it is presumed mandatory (such as in Washington state), I’ve been told that many of the family doctors have stopped prescribing opioids.
You can be the brightest, most compulsive, and most compassionate doctor, but these are the most challenging patients in medicine, so seek outside help wherever possible. To echo a statement previously published in PPM, "The Share the Risk model’s fundamental premise is that no physician—no matter how well educated, confident, compassionate, committed, or meticulous—can adequately meet all the needs of the patients with chronic and intractable pain."1
Finding a Pain Specialist Is Difficult
Jennifer Schneider, MD, PhD
There are just not enough pain specialists to care for all patients who would benefit from opioids for chronic pain. Providing education and support to community physicians is the best and most obvious way to increase the number of health care providers who are willing and are sufficiently knowledgeable to care for patients with chronic pain. For many years, I have been dedicated to educating prescribers with a goal of accomplishing just this, and I continue to teach courses on proper prescribing of controlled substances. But the current regulatory environment has made many prescribers, especially primary care physicians (PCPs) reluctant to care for such patients, especially if they are complicated.
Recently, I received an e-mail from the husband of a woman who had been on high-dose opioids for chronic pain. The physician who had been treating her suddenly shut down his practice. By all accounts, she had been a compliant patient who had been maintained on the same dose of opioids for years. Her PCP was not comfortable taking on her care, so she ended up having to travel to New York City from her home in the Midwest in order to see a pain specialist (who happened to be affiliated with one of the big medical centers). After her consultation, the pain specialist contacted her PCP and was able to convince him to take on her case. This may seem like an extreme example, but it is unfortunately becoming more and more common. Luckily this person had the means to travel thousands of miles for a consultation—but this is not practical or affordable for most patients.
When I retired from clinical practice, I found that it was not easy to get physicians to take on my patients. I was lucky in the end to find a physiatrist who was new to my city, spent some time with me to increase his knowledge base in this particular arena, and was happy to acquire multiple new patients. It is a difficult time for health care providers to get into the pain medicine field. I think that PCPs are afraid of the current regulatory climate and scrutiny—and their fears are legitimate.
There are aspects of opioid prescribing that are often not considered. For example, if you start patients on opioids, you have to have an exit strategy for getting them off. The best-case scenario is if the patient no longer needs pain medication (for example, if a knee replacement has alleviated their knee osteoarthritis pain). In such a case, it’s simply a matter of tapering the opioid to avoid withdrawal symptoms. It’s more complicated if the patient still has pain but is noncompliant. If I feel I have to discharge a patient, I write him a letter explaining that I can no longer be his doctor but I am willing to give them emergency care for the next 30 days. During that time the patient has to find another doctor. For the meantime, I will give the patient a final 30-day prescription for the pain medication (unless they are being discharged for having diverted the opioid, in which case I would not provide him with any additional opioid). I explain to the patient that if during this time period he cannot find another doctor, he needs to taper the medication to prevent withdrawal, and I provide a tapering schedule. If the patient is on high-dose opioids and would have a difficult time without opioids for his chronic pain, I recommend that he go to the methadone clinic, whose staff would transition him to methadone and maintain him on that medication.