How Should Providers Approach Pain Management During the Opioid Epidemic?

Tighter regulations surrounding opioids have presented a challenge to physicians treating chronic pain.

Prescription opioids are currently viewed as a precursor to drug misuse disorder. With many Americans dying from opioid overdoses, legislators have enacted opioid laws that limit the number of prescriptions a provider is able to write, how long a patient can take the drugs for, and increase patient education about the risks.

Although lawmakers have implemented the regulations to benefit patients, it has caused physicians to wonder how they can effectively manage patients with chronic pain who may benefit from prescription opioids. Prescribers must now use their skills to identify the patients who would benefit from opioid therapy, while operating within strict legal parameters.

Christopher J. Burnett, MD, an assistant professor of anesthesiology at the Texas A&M College of Medicine and director of the Baylor Scott & White Health’s Temple Pain Clinic, said in an article that the first step to treating patients while avoiding opioid abuse is to follow CDC guidelines.

"The CDC guidelines, which outline when to prescribe these drugs and provide guidance for how to do so safely, are a good starting point for providers caring for chronic pain patients," Dr Burnett said.

Despite concerns, these guidelines are not intended for patients receiving palliative care, in hospice, or being treated for cancer.

"If they are providing end-of-life care, providers should do what is necessary to make the patient comfortable," Dr Burnett said. "The CDC guidelines are intended for the typical chronic pain patient."

Numerous studies have failed to provide a link between chronic pain improvement and opioids, suggesting that patients are exposed to potentially habit forming treatments with little to no benefits. Sometimes the optimal care route is to not prescribe any drugs, according to the article.

"Much of the time, the right thing to do for lower back pain is to simply wait," Dr Burnett said. "It might be an acute injury that will heal on its own given a little time."

If this approach is not deemed to be the best for a given patient, providers may choose to prescribe anti-inflammatory drugs, according to the article. Additionally, providers may suggest that patients explore a non-drug therapy, such as physical therapy, transcutaneous electrical nerve stimulation units, acupuncture, and massage.

If patients do not seem to improve with the conservative approaches within 3 months, Dr Burnett suggests exploring treatment from an interventional pain physicians to reduce pain, increase functionality, and improve quality of life.

"The population of patients who need opioids chronically is actually pretty small," Dr Burnett said. "For most people, the prescription comes with an exit plan. These medications are now considered to be a way to bridge to the next line of therapy.

Non-drug therapies are intended to reduce reliance on prescription opioids, in an effort to reduce overdose-related deaths, according to the article.

"In the past, providers have been all too willing to give copious amounts of narcotics and continue to escalate doses based on reported symptoms without having a clear idea of why they're doing it or what duration," Dr Burnett said. "In my training, I have been told that if someone isn't responding to their opioid treatment, you just need to give more, and that was kind of the accepted wisdom for a number of years -- that you're just not giving enough."

While this may have been common in the past, the best practices have dramatically changed in light of the opioid epidemic. At some clinics, including Dr Burnett’s, patients are required to sign a document that outlines patients are only to only obtain the drugs from 1 provider, 1 pharmacy, and will adhere to the regimen, according to the article. These patients may be screened for illicit drugs and opioid metabolites to ensure the drugs are not being abused.

This shift has caused providers to worry about patient satisfaction — if the patient is in pain, and they believe the physician is not addressing the issue, they may not be satisfied with the care. This may affect reimbursement for certain providers.

"I have to put the patient's life ahead of the patient's satisfaction, but sometimes that can lead to low satisfaction scores,” Dr Burnett said.

Providers should also have open and honest conversations with their patients prior to prescribing opioids. Patients should be informed about the risks and how the drugs should be stored to prevent other individuals from taking the drugs, according to the article.

“They have to think about who else might be able to gain access to the pills; too many teens have become addicted from stealing opioids from a family member's prescription," Dr Burnett concluded. "It's a real responsibility to even have narcotics in the home, even when they are necessary."