Six months ago I saw a 45-year-old former athlete who had three unsuccessful back surgeries, taking 80mg of extended release oxycodone three times a day. He was also inactive and depressed despite counseling.
Just five years ago I would have increased the oxycodone to improve his pain and function. Now with opioid overdose deaths, all of us are questioning our practices. As trusted primary care providers, patients ask us if we are capable of properly managing their pain? I believe we are their advocates when it comes to treating chronic pain, just like we are for other chronic diseases.
Managing chronic pain is complicated and complex. After two decades of learning about the epidemic of undertreated pain, primary care responded by prescribing more hydrocodone than any other drug.
But the benefits of opioids were overrepresented. Safety studies that showed their prolonged effectiveness were poorly designed, with randomized trials sponsored by pharmaceutical companies lasting only 12 weeks and leaving questionable results.
Even pain experts now acknowledge that the risks of opioids were understated. Few knew that taking opioids could actually increase pain, decrease testosterone and cause respiratory arrest in patients at risk.
The FDA is asking opioid prescribers to take three additional hours of continuing education. If this is any indication, the pendulum has swung from favoring pain treatment to concentrating on opioid overuse.
The true risk of addiction with chronic opioid use is still being debated. But many of those at higher risk are also living with chronic pain. How do we find the right balance to help heal and do no harm to our patients?
Pain experts have trouble interpreting aberrant behavior in patients with depression, anxiety and chronic pain, who also take mood-altering drugs. Primary care providers who trust patients and advocate for their care have even more trouble managing this behavior.
But consider my patient who still lives with severe pain. Instead of prescribing more opioids, we negotiated alternative therapies, like chiropractic, acupuncture and surgical interventions. But when physical therapy fails, insurance doesn’t cover acupuncture and cognitive behavioral therapy, functional rehabilitation is unavailable, and my patient says that only the oxycodone offers any kind of relief, where do we go?
As primary care providers, we are especially well-suited to manage chronic disease. We do it every day with diabetes and hypertension. We listen actively and empathize. We recognize the stages of change and offer gentle encouragement to provide the best outcomes. We talk about what it means to practice a healthy lifestyle, like proper diet and exercise.
Many patients do not benefit from surgery or injections, and medications help less than 30 percent.
Despite multiple failed therapies, my patient is in a better place. He still takes oxycodone but with my help and constant pressure to get more active, he gradually increased his exercise and re-engaged in social activities. He connects with friends and family and is now coaching high school track. He also is asking me how to taper off oxycodone.
If we are doing all we can to manage our patients’ overall health, can we ask for any greater success in primary care?
Bill McCarberg is a primary care physician and is president-elect, American Academy of Pain Medicine.