Jeremy Adler, DMSc, PA-C, DFAAPA, leads discussion on elements that negatively impacts the quality of care for patients requiring pain management.
Peter Salgo, MD: Why don’t we take a look very quickly—let’s discuss some real important things here, some challenges surrounding opioid misuse.
We have physicians inheriting patients with chronic pain who are already on opioids. Do the physicians look upon these patients and say, “No, I don’t want you in my practice”? What do they do?
Jeremy Adler, DMSc, PA-C, DFAAPA: Typically, it is really challenging for a patient who is taking an opioid—especially if it is an appropriate patient receiving it—to find somebody to care for them. On the flipside, when you receive patients who are on opioids, you were not involved in patient selection, patient screening, or risk assessment. All the complex factors that go into selecting a candidate for an opioid are out of your control when a patient presents themselves and they are on an opioid. That creates a challenging scenario in terms of what to do now. You start your risk assessment. You determine if they actually adequately looked at nonopioid therapies and nonpharmacologic measures. How has this patient been treated? Time is of the essence because, often, there is an individual at the other end of it, another prescriber, who is done. They, for whatever reason, have decided they no longer want to care for this patient, and there is this emergent period with limited resources and limited information.
Theresa Mallick-Searle, MS, RN-BC, ANP-BC: We see this a lot in academic medicine. If you are fortunate enough to live in an area where you have an academic medical center that has a tertiary pain clinic, then that tends to be where all the patients go. We have seen a lot of that. Not only are the patients feeling overstressed—just getting back to a level of appropriate mental health—but they’re also feeling abandoned. When those patients get dumped into another facility, to get somebody else to take over the writing of their prescriptions for opiates, then there is this issue of trust, and it is almost a battle.
I agree with everything Jeremy said. It is a challenging situation that you find yourselves in, but it’s real.
Peter Salgo, MD: We have even some of the basic nuts and bolts of medicine here; for patients on opioids with renal failure, how are you going to transition them onto something else when patients have issues with the half-life of their prescription? If you have stable patients on long-term opioids, and suddenly everybody is being told, “You have got to wean these patients off these medications,” what is a physician to do?
Charles Argoff, MD: One of the first steps is to determine whether weaning is the appropriate thing to do. For some people, opioids are the best option, and we can discuss that if you’d like. In other instances, and I think others have already pointed this out, pain management is very complex. Jeff mentioned this. If you are in a resource-poor area, and you move to a research-rich area like Palo Alto, California, you may have gone from a situation wherein opioids were the only thing you had to offer, and it was no fault of your own, but now you are going to Stanford Health Care, and you’re exposed to the best, the latest, and the greatest. It is like, “Wait, this could better for you than opioids.” We have to contextualize this discussion so that we understand that.
Peter Salgo, MD: I would just like to point out that, having been to the Palo Alto campus, I can say it is the most beautiful hospital I have ever seen, and we all hate you very much, Theresa.
Jeremy Adler, DMSc, PA-C, DFAAPA: One of the things that has been a challenge, especially with this notion of tapering—this idea that the opioids should not be a part of many patients’ treatment plans— has been the lack of support for nonopioid and nonpharmacologic measures. Things like physical rehabilitation, mental health services, interventional pain management, all the different options that we may be able to provide, even other drug therapies that may have some benefit for these patients—the cost and access issues are enormous. And for many of the health plans, opioids do not seem to carry as much of a cost burden in comparison. There is this struggle between coverage, access, and the standard of the current clinical guidance.
Jeffrey Bratberg, PharmD, FAPhA: How do primary care doctors get physical therapy for themselves, much less for others? Privileged, established, and educated folks often cannot get physical therapy themselves. My colleagues in health care may say, “I have this problem; I know it’s the best treatment for low back pain,” which is 1 of the top 5 pain-related syndromes in primary care. But even if they are in a resource-rich area, they still need transportation, they still need an appointment. COVID-19 has also limited physical therapy, and physical therapists going into homes. So we have that complicating this whole effort as well.
Peter Salgo, MD: I want to hit a few of these topics very quickly. There was a misperception…, “Oh, prescription narcotics are less harmful than illicit drugs. Prescription opioids—they’re not addictive at all. It is only the illicit ones.” We have got to address these at some point. Both of these assumptions are false and potentially harmful, right Jeff?
Jeffrey Bratberg, PharmD, FAPhA: They are. When looking at pharmacologic qualities of opioids, they vary. Buprenorphine is a fantastic pain treatment; it also treats opioid use disorder, but it is highly stigmatized, and people do not think of it as a pain reliever. Even pain specialists and primary care doctors are uncomfortable prescribing it. They do not have a waiver, so there are limits for this very safe drug that very effectively treats pain on a short- and long-term basis. I think there is a stigma against opioids, where practitioners will say, “I’m going to give you your 2 doses or your 5 days’ worth after a legitimate, severe surgery,” for a person who probably needs opioids, and people don’t want to take it even then.
I think we have to consider any potential harm looking at the patient as a whole: patients themselves, their environment, and access to other kinds of care.
Peter Salgo, MD: This circles back to the question I had right at the very beginning. When using a blanket term like “crisis,” making it political, and then pointing fingers, the subtly of the discussion is lost. That is what you are pointing out. It is a textured issue.
Transcript Edited for Clarity