By: Dr. Geoffrey Modest
The Massachusetts Medical Society just sent out guidelines on opioid therapy prescribing (see here). A brief summary:
–most of the guidelines are pretty self-evident:
–for initiation of opiates: screen the female patients for pregnancy (and counsel re: risks)
–do some form of screening for risk of opiate abuse [i would add that the website mytopcare.org has lots of useful tools for opiate prescribing, including an opioid risk tool to assess for risk of opioid addiction. I would also add that this type of risk tool is a not-completely-accurate instrument].
–inform patients of cognitive issues with taking opiates, and potential risks of operating heavy machinery, driving
–consider consultation if patient has complex pain issues with serious co-morbidities and mental illness, or history of substance abuse disorder
–use opiates at the lowest dose and shortest duration possible
–review other meds being taken, which might increase the risk of opiate harm (eg benzodiazepines)
–regular patient visits to assess progress (function, pain) and reconsider the continuing need for opiates
–chronic opiate usage (>90 days): “consider” consulting with other physicians as part of developing and implementing an ongoing treatment plan
–perform appropriate baseline urine drug testing if risk assessment suggests there may be issues with other drugs [our practice is to do this pretty regularly on almost all patients]
–there should be a re-evaluation of the treatment plan and goals every 60-90 days
–best to have a written treatment agreement, updated annually, signed by the patient and physician, to include goals of therapy (such as improving function and quality of life, control pain, when it is okay to get opiates from other providers, and what the goal is to reduce the opiates to the lowest level possible to control pain and preserve function)
–discuss risks of dependence and addiction; discuss/offer naloxone
and, the more controversial
— “physicians who are not pain management specialists should not initiate treatment plans which call for in excess of 100 milligrams of morphine equivalent opioids per day without a documented consultation with a pain management specialist”
–“if a patient is currently receiving > 100 mg morphine equivalent per day, a plan should be instituted to begin tapering of the dose, and if not possible to do so, consultation with a pain management specialist should be obtained.”
So, this really brings up a few issues. Part of the issue is that we in primary care are being pretty rapidly buffeted by opposing winds. First, the Institute Of Medicine came out with a clear proclamation in the 1990s that we were undertreating pain. This was augmented by the rather seedy/self-serving Purdue initiative (makers of oxycontin) to make pain the 6th vital sign (which catapulted oxycontin, their drug, into a blockbuster for them). Now we are confronted with the very real prescription drug mortality epidemic, raging out of control. And the response is to put a ceiling on primary care prescribing (stigmatizing both providers and patients), unless we get the approval of a pain clinic. So, here are a few of my random thoughts on this (the issue of opioid use is quite complex, so these points are hardly all-inclusive):
- The overdose/death rate for prescription opioids is staggering and a clear social issue, and we as providers should be part of the solution
- There are real concerns about prescription opiates now being “gateway” drugs to more high risk behaviors: I have seen and read about many patients taking prescription opioids who can no longer afford them and are switching to street heroin, with its profound risks.
- But for an individual patient, there are clearly many who need and benefit from opioids (though there are some interesting genetic issues here, see the blog: here)
- It is rather striking that, given how common the opiate-prescribing issues are, there are a truly remarkable dearth of studies on opioid use – for example, there are NO (ie, zero) randomized controlled studies looking specifically at whether higher dose opioids are more effective than lower dose (and, if higher doses do in fact work significantly better, this might justify using a higher dose in some patients even if there is a higher associatedrisk). This fundamental lack of data makes it difficult to accept a guideline approach of considering 100 morphine-equivalents as the top dose that we should use in primary care. And, there are not even data on the widely held concept that, for chronic pain, we should use a basal long-acting opiate augmented with a short-acting one for break-through pain (and there even are some data to the contrary).
- The concept of needing to get a chronic pain consult after a certain level of opiate use is pretty insulting to us in primary care. We are not forced to get consults around other issues. If someone has hypertension uncontrolled on 4 meds, we do not need a hypertension consult. Or a cardiology consult for a person with atrial fibrillation. And, most of the patients we see on chronic opioids have very complex psychosocial situations, often with underlying psych issues (depression, PTSD, history of domestic or sexual violence, trauma), personality issues, physical trauma (severe accidents) etc. It typically takes us many sessions with a patient to unravel and understand the complexity of care for the patient, for which opioid use is only part. Prescribing opioids has to be understood in this greater context. Although pain clinics might help in some patients in making suggestions about adjuvant therapies or other approaches, it really is us guys in primary care who are in the position to really understand the patients and put all of the pieces together. Hard to replicate this understanding in a single visit with a pain specialist. So, I would agree that in some cases a pain consult is likely to be helpful with specific questions about medication management or other interventions, to me it makes little sense to mandate one for all patients at some arbitrary medication dosage (especially since this not backed by any evidence-based studies). And, of course, I really doubt there is the capacity in pain clinics to see all patients on >100 morphine-equivalents.
- Even for issues such as the combined use of opiates and benzodiazepines, there are only observational studies which show a higher mortality. But we know that several of the underlying diseases themselves often treated with benzos have an increased mortality (eg panic disorders). And even if the benzos are associated with more adverse events, there clearly are patients who really need the benzos to function and are willing to take the risk of adverse events (as we do all the time: whenever we prescribe medications, we are balancing the benefits and risks, whether that is the unlikely risk of death from a sulfa drug – which I have seen twice, or the higher likelihood of adverse events with cancer drugs). Clearly we should minimize giving any drugs unless they are really indicated, but the issue of benzos and opiates is not fundamentally different from that of other issues we deal with in primary care on a daily basis.
- I think our job in primary care is really to develop relationships with patients. Those who are on or need opiates typically fall into one of 3 categories:
–Those who clearly need opiates to function (eg cancer patients with pain, but also many people with severe knee arthritis who need opiates to be able to walk, and personally, I don’t think we should treat these patients differently even though the cancer patient with pain has a more socially-acceptable diagnosis. And despite geriatric societies putting opiates on their “do not use” list (risk of falls), I do have some quite old patients who really need them to function at all, as well as remain reasonably pain-controlled, as I do with some elderly cancer patients.
–Those who are pretty likely addicted to the opiates, use multiple potentially hazardous illicit drugs, or are likely diverting/selling the opiates. Here, providing opiates may well be harmful to the patient or society. It seems to me that this is the group we need to work with, develop relationships with, and try to help them/support them as best we can without providing opiates (or, if addicted, consider using buprenorphine along with counseling/support)
–Those in the middle. We are not sure if the 30 year old with back pain really has so much pain to require high dose opiates. We can try to give objective tests of function or standardized questionnaires, though pain is fundamentally subjective. We get insights by observing function, pain symptoms as people walk in the hallway or climb onto the examining table or more extensive testing. We get additional information by doing random urine tests, pill counts, checking prescription monitoring programs. Those who screen positive on the opiate risk tool are more likely to be in this category (or the one above). We review and sign controlled med contracts (which we do with others as well, though their clear benefit is not well tested). And, hopefully, through developing a relationship, try to sort out what’s going on in order to best help the patient.
- And, one big issue, is that if someone is on >100 morphine-equivalents, and there are guidelines as above, that confers a strong medicolegal aspect to the situation: if someone is on 120 morphine-equivalents and has a bad outcome, we as primary care providers could be sued for not adhering to the “professional society guidelines”. Not that we should just practice defensive medicine, but I have seen a few providers who have been sued (inappropriately, in these cases), and I can tell you it is a really awful experience for them even though they were right.
- But, with all of this ranting, i do think we as primary care physicians do have the individual patient and broader social responsibility to try to ensure that our patients who are on opiates really do need them, they are on the minimum amount to allow them to function, we try to avoid using benzos with opiates if possible, and we set up systems to make help prevent opiate diversion and misuse.