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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.

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:

  • Average pain
  • How the pain interfered with enjoyment of life
  • How the pain interfered with general activity

 If the patient’s level of functioning and quality of life are stable with the current opioid therapy, he or she has not requested to taper, and there are no other overriding factors, then the PCP and the patient may choose to leave the current dose unchanged. In that case, the PCP is reminded to document both the conversation with the patient and the results of the functional assessment in the patient’s file. If the functional assessment suggests that the patient is not obtaining benefit from the opioid therapy, or there are other indications, such as those outlined above, then a taper should be attempted.

Opioid Tapering: Patient Care Best Practices

Most research on opioid cessation focuses on treating addiction, the compulsion to continue using these drugs despite the negative effects they are having on one’s life and health. Protocols for helping addicts detox are readily available. For chronic pain patients who have become physically dependent on long-term opioid regimens, however, little evidence-based research exists, and there are few protocols for physicians to follow (See Q&A).

To provide the best care, therefore, the PCP must rely on experience, consultations with colleagues, pertinent literature, and his or her own understanding of the patient. After reviewing the available resources5-7 and my own experiences, I would offer the following 10 recommendations for PCPs with patients on chronic opioid therapy:

  1. For established patients, periodically introduce the topic of opioid tapering after a review of the indications listed above. For new patients already on chronic opioid therapy, introduce tapering upon intake. It is important to remember that some medications cannot be stopped abruptly; many require a weaning period. (Note: Whenever starting a patient on an opioid regimen, the physician should make sure the patient understands that these drugs should not be stopped suddenly.)
  2. Emphasize the availability of support during this process and your willingness to slow the taper if necessary, explaining that the process may take months.
  3. Obtain a functional assessment of the patient’s current pain control using functional assessment tools, such as the PEG scale, at the start and then periodically thereafter, typically after a significant reduction in the opioid dose.
  4. Use an end point for cessation of the taper, either the cessation of all opioid use by the patient, or a significant change in the patient’s  functional assessment score from baseline.
  5. Consider consolidating multiple opioid agents into a single long-acting agent of similar MME and taper from there once the patient is stable, as suggested by the American Academy of Family Physicians (AAFP).8 (Note: Many patients may object to the switch from short-acting to long-acting opioids. Take the time to explain your rationale, risks vs benefits, cost, etc.)
  6. Start slowly, tapering 10% to 20% of the original MME every 2 to 4 weeks. Although, as already noted, there is no evidence for the time course for any tapering protocol, I have found this timeline works best in my practice. See the patient frequently during this time, and consider slowing the taper if a patient’s symptoms and functional scores indicate increased distress.
  7. Before starting a taper, start and optimize the nonopioid adjunctive therapies indicated for a particular pain syndrome, which will increase the likelihood of success. In addition to nonsteroidal anti-
    inflammatory drugs (NSAIDs), antidepressants, seizure medications, and topical pain treatments, other adjunctive therapies, including physical therapy (PT), chiropractic care, acupuncture, and massage therapy, can help patients wean off long-term opioid regimens. As opioid dosages are reduced, these therapies provide pain relief and help improve compliance.
  8. Document the tapering process thoroughly and make sure to incorporate the functional assessment tools used, along with the patient’s scores.
  9. Note that most patients on chronic opioid therapy are willing to consider a taper if they are approached in a supportive manner. Let them know that a taper can be slowed or restarted at a later date based on their response.
  10. Make sure to warn patients that, once tapered, they will lose their tolerance to opioids and will be at risk of accidental overdose if they were to abruptly restart their original dose.

Practice Barriers

Although many useful therapies exist and more are being developed, patients trying to access them frequently encounter obstacles. Insurance companies often do not cover PT, acupuncture, chiropractic care, or massage therapy, and when coverage is provided, it may not be for a complete course of treatment. Prior approval often is required as well.

Adjunctive therapies also are not available in all parts of the country, and, even when they are, transportation may be an issue. This is especially true in rural areas where facilities might be located many miles from a patient’s home.

Pressures to reduce exam time also make it more difficult for PCPs trying to help individuals taper their long-term opioid treatment. Requirements for managing coexisting diseases all must be met during the limited time the provider has with the patient, reducing the time available to address pain management concerns. In addition, personnel limitations, which are dictated by practice reimbursement, may result in insufficient ancillary staff to assist with the screening and monitoring required for optimal care.

AAFP Resources Available To the Family Physician

In response to the opioid problem, the AAFP has developed policies, programs, and partnerships to advocate for and educate family physicians and to promote public health. The AAFP has collaborated with multiple external organizations on programs that address the opioid problem, including the Department of Health and Human Services’ National Pain Strategy, which supports provider education and training and supports increased public education and communication.

As part of its commitment to physician education, the AAFP has developed multiple continuing medical education (CME) activities focused on opioids, pain management, and substance abuse, which are available in live, online, and webinar formats.8 It also offers a provider toolkit that includes an opioid risk assessment tool, a sample practice agreement, an opioid tapering guide, and urine drug testing information, among other resources.9

Final Thoughts And Suggestions

A recently published position paper by the AAFP states, “Both pain management and dependence therapy require patient-centered, compassionate care as the foundation of treatment.”10 This is precisely the kind of care at which PCPs excel.

For PCPs caring for chronic pain patients, I offer the following advice. Avail yourself of the many tools available through the AAFP and similar organizations. Assess your patients completely, using all available resources. Keep in mind that not every patient who presents with escalating pain relief demands is misusing or abusing analgesics, nor is the seemingly compliant patient always innocent of misusing or diverting medications. Treat all patients with respect and be open and honest with them, and with yourself, about your comfort level providing their pain care.

Last updated on: December 28, 2018
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Insurers End Policies Requiring Prior Authorization for Opioid Use Disorder

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