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12 Articles in Volume 17, Issue #2
Chronic Pain and Bipolar Disorders: A Bridge Between Depression and Schizophrenia Spectrum
Differences in Pain Management of Peripheral Vascular Disease and Peripheral Artery Disease
Duloxetine and Liver Function Tests
How Well Do You Know Your Patient?
Insurers End Policies Requiring Prior Authorization for Opioid Use Disorder
Letters to the Editor: Initiating Hormones
Managing Opioid Use Disorders and Chronic Pain
Opportunities and Challenges of Pain Management: The Family Physician’s Perspective
Pathways to Recovery From Co-Occurring Chronic Pain and Addiction
Strategies for Weaning Opioids in Patients With an Opioid Use Disorder and Chronic Pain
Treating Multiple Pain Syndromes: A Case Series Using a Functional Medicine Model
Treatment of Chronic Exhaustion and Chronic Fatigue Syndrome

Opportunities and Challenges of Pain Management: The Family Physician’s Perspective

Safe and effective pain management involves setting realistic treatment expectations with the patient, including when and how to wean off opioids.
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Primary care physicians (PCPs) are tasked with managing multiple diagnoses, including many diseases accompanied by chronic pain.

The role chronic pain plays in the clinical setting varies. For the PCP, a patient visit may be dominated by concerns about pain to the exclusion of all other health issues, or it may entail nothing more than a request to refill an analgesic prescription as the provider leaves the exam room. The PCP may see patients who have grown physically and functionally dependent on a long-term course of opioids, as well as those who have become addicted.

Increasingly, as the medical profession confronts the unprecedented opioid abuse epidemic, family physicians are being called on to help chronic pain patients taper their doses and, if needed, get addiction treatment, including a detox program and medication-assisted treatment.

10 recommendations for primary care physicians to provide chronic pain therapy to patients.

There are evidence-based protocols for detoxing addicted patients, but none exist for tapering a chronic pain patient. The latter requires physicians to create individualized treatment plans for each patient. How and when the medication is reduced depends on the patient’s pain level at each step and demands the physician’s utmost attention and expertise.

This article provides a family physician’s perspective on chronic pain management, with a focus on how to help patients safely taper opioid medications.

New Guidelines

Deaths from drug overdose increased nearly 300% from 1999 to 2014, and in 2014, over 60% of those deaths involved an opioid (including those obtained by prescription and illicit sources). According to the most recent Centers for Disease Control and Prevention (CDC) data, deaths from all classes of opioids (natural, semisynthetic, and synthetic) continue to increase.1

In response to this epidemic of opioid abuse, multiple organizations, including state and federal agencies, state licensing boards, and professional associations, have developed new guidelines. Although these guidelines consist of multiple “commonsense” components, they represent a combination of consensus and expert opinion, both of which may be subject to bias. Until further evidence-based research becomes available, this mix of common sense, consensus, and expert opinion will remain the basis for these guidelines.

PCP Responses

No published research is available regarding PCP attitudes regarding the new recommendations and the effect they are having on prescribing practices. As a family physician and provider of pain services, as well as an educator of PCPs, I have observed the following responses to the new guidelines most commonly among family physicians. Physician attitudes can be summarized generally with these 3 statements: “I will deal with it,” “I am fine with the guideline,” or, increasingly, “I don’t prescribe opioids.”

The “I will deal with it” group tends to consist of older, established PCPs caring for larger numbers of chronic pain patients and most often practicing in rural areas. These PCPs usually are in smaller independent practices, often working under the real or perceived notion that there are few, if any, resources available to care for the chronic pain patient in their location.

PCPs stating that they are “fine with the guidelines” tend to have been previously exposed to more formalized pain management training or guideline use in general. These physicians often are associated with larger practices that have access to additional resources devoted to organized pain care.

The final response, “I don’t prescribe opioids,” represents a growing portion of PCPs and is most common among newly trained family physicians and those approaching retirement. This response also is increasingly observed among PCPs who have received, or who anticipate receiving, scrutiny from the various regulatory agencies.

Although the above characteristics are generalizations subject to confirmation through research, in my experience, they represent the most common responses of PCPs to the new guidelines.  

Treatment Approaches: Opioid Tapering

In the ongoing management of established chronic pain patients receiving chronic opioid therapy, PCPs are increasingly considering the possibility of an opioid taper. Potential indications to consider a taper include:

  • A patient request to reduce or stop his or her opioid therapy
  • A lack of significant improvement in pain or functioning
  • The occurrence of an overdose or other adverse event (AE)
  • Changes in the patient’s coexisting medical conditions that would increase the risk of an AE
  • Noncompliance with the treatment plan
  • High-dose opioid therapy (defined by the recently released CDC guidelines as >90 mg morphine equivalent [MME]),2 particularly when the patient also is taking a benzodiazepine3
  • Signs of misuse or abuse of their chronic opioid therapy
  • The imposition of treatment rules or regulations that limit the PCP’s ability to prescribe opioid therapy

When considering the possibility of an opioid taper, a physician must perform an assessment of the patient’s functional level using various assessment tools, such as the PEG scale.4 The PEG consists of a questionnaire that uses a 10-point scale for the following 3 areas covering the patient’s experience over the past week:

Last updated on: March 17, 2017
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Insurers End Policies Requiring Prior Authorization for Opioid Use Disorder

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