A Smokejumper’s Thoughts On Opioid Pain Management

I realize it has a been a while since my last post and I can tell you that it’s mainly because I’ve been getting a lot of business in the last week and a half. As the main steady smokejumper Psychosomatic Medicine specialist for the general hospital, the average number of calls has been creeping up. Part of the reason I like it is the variety of interesting situations into which I jump.

A big challenge about the variety is that a growing proportion of the calls I get are in the aftermath of accidental or intentional overdoses of opioids and benzodiazepines. Iowa is no different in this regard than any part of the country. I can see why some doctors are confused about benzodiazepines.

However, other physicians are pretty sure of themselves about the dangers of benzodiazepines, especially when combining them with opioids. They have petitioned the FDA asking that a Black Box Warning be issued in order to caution doctors about prescribing them together. Read the actual petition for details.

And it’s hard to miss the flurry of national and state legislative activity and the mobilizing of regulatory and educational efforts directed at doctors, especially primary care physicians. The new CDC opioid prescribing guidelines are clear–they’re obviously designed with the idea that doctors need more education about the problem.

Psychiatric consultant as smokejumper

Psychiatric consultant as smokejumper

As a smokejumper, I often find a number of fires in situations like this which I can’t readily put out, at least not by myself. I usually try to reach out to practitioners and foster a conversation about the crisis and I often get the impression that simple educational efforts may miss the mark, although I definitely support this effort.

In the real world of general hospital psychiatry, I rarely find straightforward explanations for overprescribing by doctors and misuse of medications by patients. There might be assumptions about chronic pain and anxiety on both sides and inertia regarding change can play an important role in persisting use of these medications even in the face of unclear indications and dangerous outcomes.

Efforts to persuade and educate physicians about the dangers of prescribing opioids and benzodiazepines has been going on for many years. Some states, including Iowa, have mandates which require any physician providing primary care to participate in mandated chronic pain management CME in order to obtain or renew a state medical license.

Even I have to participate–even though I can’t remember the last time I wrote a prescription for benzodiazepines or opioids. And I don’t consider myself a primary care provider.

I suspect that the complicated relationship between doctors and patient may play an important role in the continued prescribing of and requests for opioid analgesics and benzodiazepine anxiolytics. This is not just a simple apology for what many perceive as a black and white problem of the “bad” overprescribing doctor and the “bad” drug-seeking patient and the “good” regulatory agencies and patient advocacy groups.

Life is not that simple.

There are a few reasons I can think of which can slow down the impetus to opening what can be a difficult conversation between doctor and patient:

The physician and the patient both believe that benzodiazepines and/or opioids are appropriate and effective for pain and anxiety and the patient is not suffering any side effects and is not seeking prescriptions for these drugs from other prescribers as well, not running out of medication early or running to other pharmacies, and not suffering withdrawal or intoxication. This doesn’t get media attention and we don’t know how commonly this happens.

The physician may be assuming care of a patient seen by a colleague or another doctor from another practice who is not a colleague. If the patient is taking substantial doses of opioid and/or benzodiazepine, the physician may be reluctant to risk causing withdrawal and continues the medications. This can lead to inertia and the continuation of a prescribing pattern which may not be in the long term best interests of the patient.

The physician may be temporarily covering for a colleague who may be on vacation, ill, or absent for other reasons, and reluctant to change a treatment plan that has included benzodiazepines and/or opioids.

I’m sure physicians and patients can think of other reasons.

There are so many papers and news stories about hazards of these medications, especially opioids, that it can be difficult to find one written for patients and physicians who need guidance about safe ways to implement opioids for those who may benefit from taking them. One such paper is published in the Rounds in the General Hospital section of The Primary Care Companion for CNS Disorders [1]. This paper was also remarkable in that a couple of medical students made substantial contributions to it, led by Dr. Theodore A. Stern, MD, a leader in Psychosomatic Medicine. That doesn’t mean I necessarily agree with each and every point the authors make, although I think the observations and recommendations are practical.

Now, fair use restrictions prevent me from sharing the entire paper with you. However, I think I can extract key concepts and pass them on while urging you to read the entire paper yourselves. Some prescriber factors that influence the prescription of opioids including the fear of addiction, causing physical harm, worry that a patient is misrepresenting pain, not knowing enough about pain management nor having the skills to assess and manage pain, and worry about medication diversion. What can help are treatment contracts, CME, referral of the patient to specialty pain management clinics, and having a frank (if difficult) conversation with the patient about the pros and cons of opioids and the utility of random urine drug screens.

Systems challenges influencing opioid prescription include the regulatory barriers and fragmentation in the health care system (including but not limited to multiple providers) which tends to promote the risk of opioid abuse, and the current lack of courses on pain management in medical school and residency. According to the authors, physicians can reduce the risk of opioid abuse by doing the following:

  • Before prescribing, think carefully about whether opioids are appropriate and whether alternatives have been exhausted
  • Use treatment contracts which specify that opioids are to be used only as prescribed from a single provider.
  • Obtain a baseline urine drug sample before implementing opioid treatment because this may identify those at risk for misusing opioids. Routine urine drug testing can help reduce the risk for nonadherence and diversion.
  • Physicians can foster a collaborative relationship in the pursuit of pain management using open communication which emphasizes both frankness and empathy.

Reference:

Wallwork, R. S., BA,, et al. (2015). “Obstacles to the Prescription and Use of Opioids.” The Primary Care Companion for CNS Disorders 18(01): 1-11.
Have you ever wondered why physicians try to avoid prescribing opioids for patients with chronic pain? Have you ever struggled to decide whether prescribing opioids is appropriate or wondered how likely it is that one of your patients will become dependent following prescription of an opioid? If you have, then the following case vignette and discussion of patient, provider, and system factors that interfere with prescribing an opioid should prove useful.

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Comments

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  2. Hi Jim,

    There are problems with the author’s suggestions.

    Since the population at risk for addiction cannot be identified prospectively any trial of opioids already has placed them at risk. Gone are the days when we can believe the risk of opioid use or addiction that were extrapolated from VA studies can be believed. I have seen hundreds of people who had their first experience with a legitimate prescription and had such a profound euphorigenic effect that it was off to the races. I saw them after the addiction was firmly established but it did not take long. By that time many of them were heroin users and the CDC and NSDUH have only recently recognized that this can be a problem started by exposure to prescription opioids.
    The euphorigenic hypomanic pathway to addiction is well known to addiction specialists who are focused on how addiction drugs affect conscious states. Koob’s quote in this are about how addiction progresses is well known: “Addiction is a chronic relapsing syndrome that moves from an impulse control disorder involving positive reinforcement to a compulsive disorder involving negative reinforcement.”

    The real danger from opioids is that person, not the person who gets deathly ill when they take opioids or gets adverse effects from higher doses. We don’t know what percent of the population has the euphorigenic phenotype but judging by the current epidemic – it is significant. My speculative better approach if opioids are going to be prescribed would be to tell the person about this reaction to the drug. It would be ideal to give them a test dose in the office, but our managed system of care doesn’t care about rational approaches to care. Alternately – advise the patient that if they get euphoric, ecstatic, energetic, and fell like they have become the person they always wanted to be to call immediately and consider other treatments.

    There is no evidence that treatment contracts do much. It is a good way to spell out the treatment contract. I agree that they can be a good indication of diversion, but the key question to ask is: “What happens if the tox screen turns up positive for THC?” Does that mean the patient is disenrolled from the clinic or is that acceptable because marijuana (in some states) is now “medical”?

    I think the authors also miss on the “collaborative relationship in the pursuit of pain management using open communication which emphasizes both frankness and empathy.” Certainly empathy and openness is needed in clinical interaction but it is not sufficient in the case of a person with an addiction. It is that issue that makes this much more than a cognitive issue that so many politicians and administrators would have us believe is the source of the problem. Let’s not forget that this opioid epidemic started because many of these same folks were saying that physicians had a cognitive deficiency when it came to the treatment of pain. I have a few useful graphics on the issue of overprescribing and addictive drugs:

    http://gdpsychtech.blogspot.com/2016/03/prescriber-relationship-when-using.html

    I think that several dynamics are covered there that don’t typically get discussed and that are not amenable to political or administrative intervention.

    And BTW – keep putting out fires. I too believe that there are people out there who take what I consider to be outrageous combinations of medications. If they are doing well and they have a solid relationship with a primary care physician – this is not a fire. Move on!

    Cheers!

    George

    George Dawson, MD

    Liked by 1 person

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