Steps for Primary Care Providers to Improve Opioid Prescribing for Chronic Pain

Internal Medicine World ReportJuly 2014

One of the most common treatment courses for chronic pain is comprised of prescription opioid medications. However, concerns about drug addiction and abuse oftentimes outweigh the drugs' pain-relieving benefits.

One of the most common treatment courses for chronic pain is comprised of prescription opioid medications. However, concerns about drug addiction and abuse oftentimes outweigh the drugs’ pain-relieving benefits.

Martin D. Cheatle, PhD, and Cody Barker of the Center for Studies of Addiction in the Perelman School of Medicine at the University of Pennsylvania recently published a report in the Journal of Pain Research on the risks and rewards of opioids. The work mainly targeted primary care providers (PCPs) who “typically have limited time, training, or access to resources to effectively and efficiently evaluate, treat, and monitor these patients, particularly when there is the added potential liability of prescribing opioids,” the authors noted.

In addition to physical symptoms, many chronic pain patients experience mental complications that can make treatment decisions more challenging for PCPs, the researchers said. According to several reports, comorbid depression rates vary based on clinical setting, “ranging from 85% in dental clinics specializing in chronic facial pain, to 52% in pain clinics, 27% in primary care clinics, and 18% in population-based settings.”

Although the authors contended that a primary care clinic is not an ideal setting for chronic pain management, they conceded that it is often the only place where patients can access the help they need.

“Theoretically, patients with chronic pain are complicated and would be best managed in an interdisciplinary pain clinic with access to pain medicine, behavioral health, and addiction specialists,” Cheatle and Barker wrote. “The interdisciplinary pain care model relies upon a team of healthcare providers, each with unique skills that serve as collaborators that share consensus-based treatment decisions and goals.”

However, the 3,500 certified pain physicians in the US “cannot manage the approximate 100 million patients with chronic pain, leaving the majority of pain care to be delivered by PCPs,” the authors relented.

In addition to the potential for drug addiction and abuse, patients who receive opioids may experience other complications that include constipation, nausea, sedation, sleep disturbance, and the risk of falls and fractures, especially among older patients. While the researchers noted that “many of these adverse effects can be mitigated with dose adjustment or addition of other medications, such as testosterone supplements for androgen deficiency and bowel regimens for constipation,” they said “of greater concern is the rising prevalence of opioid misuse, abuse, and fatal overdoses.”

Despite a reduction in the number of people reportedly taking extended-release oxycodone illegally, 4.9 million people aged 12 years or older were “current nonmedical users of pain relievers” in 2012, Cheatle and Barker wrote.

“The subset of patients that misuse, abuse, or overdose on prescription opioids is heterogeneous in nature and difficult to predict, particularly in a busy PCP setting,” the authors noted. Still, they advised PCPs to take steps to ensure the proper use of opioids, such as an initial evaluation and risk assessment, clinical interview, and regular urine drug monitoring.

“If a patient being considered for chronic opioid therapy is at moderate-to-high risk for opioid misuse/abuse based on the initial clinical interview, it may be advisable to obtain a baseline urine drug test for current illicit drug use of non-prescribed opioids, benzodiazepines, and stimulants,” the researchers wrote.

Other processes that may aid chronic pain patients include mental health and sleep disorder screenings, the latter of which are vital because “up to 70% of pain patients (note) significant sleep interruption,” Cheatle and Barker said. However, “the literature on the effect of opioids on sleep yields contradictory results, with one study demonstrating improvement in sleep quality and efficiency, and several other studies reporting that opioids can cause inhibition of rapid eye movement and nonrapid eye movement phases of sleep,” they noted.

Reviewing the sum of the data, the authors said “patients suffering from chronic pain conditions tend to have complicated etiologies and significant noncommitant medical and psychiatric disorders.”

“Managing chronic noncancer pain (CNCP) with opioids can be efficacious for a subset of patients; however, the rate of opioid misuse/abuse, diversion and opioid-related overdose is not inconsequential,” they said. “The clinician must balance the ethical obligation of providing effective pain relief but not exposing a vulnerable patient to potential development of an opioid use disorder. Substantial work is required to further develop, rigorously test, and refine evolving models of care and technology-assisted interventions to support the PCP in managing the growing number of patients with CNCP.”

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