Primary care providers are well-suited to manage chronic pain

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.

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  • Kristy Sokoloski

    I would love it if my Primary Care Physician could manage my chronic pain, but unfortunately because of the issues with opioid overdose and such he and his partners can’t do that anymore so they have to refer out to Pain Management. And that’s ok. However, he did recommend that I try yoga to try and help some of my pain but I am not able to do that due to the religious connection tied in to it.

    • Teresa Brown

      Not all yoga has a tie to spiritism/religion. I got a DVD called “Yoga for Seniors” and basically it’s stretching and relaxed breathing. No chanting or any of that stuff. I found that when I was doing it faithfully, my balance issues and weakness from chemotherapy were much improved. Unfortunately, multiple fractures and surgery have me sidelined.

      • Kristy Sokoloski

        Interesting, but those poses that are for seniors still have to do with religious connections. They are also poses that go with the prayers of the Hindi faith. As I told Sarah there is indeed a religious connection to it because I did extensive research on it. The yoga poses are meant to get the person ready for the next part of the religious rituals that they practice.

        • SarahJ89

          Whatever that might be. I wouldn’t know because no one has ever tried to make it religious. You must have gone to some pretty strange yoga classes. Do you think if I took bread and wine to India and share it with people it would have some magic powers because it’s part of a Christian ritual?

    • SarahJ89

      Kristy,
      Yoga doesn’t have to have anything to do with religion. I’m an atheist and there’s no religious component whatsoever to any yoga classes I’ve ever taken. It’s a systematic stretching of muscle groups that fosters relaxation.

      You can lard it up with religion if you want to, but it’s really pretty body focused. What you do with the resulting relaxation–tuning into some Hindu deity, prayer to the Christian god or simply being open to your own unconscious–is strictly up to you. I mostly just veg out.

      • Kristy Sokoloski

        If you look at the history behind yoga it does have plenty to do with religion. There is indeed a religious component to the class even though they won’t outright tell you so. I researched the history of it quite extensively.

        • SarahJ89

          I’m well aware of the history of yoga. I simply don’t care if yogis of years ago believed they had “special powers.” Are you afraid of being contaminated somehow by someone else’s religion? I’m not. I repeat: there is no religious component to the yoga classes I’ve attended. It’s history in another country is irrelevant to my experience. Which could be yours if you weren’t so afraid.

    • EmilyAnon

      My health club offers yoga as an exercise class, more specifically stretching, balance and strength. It improved some arthritis issues and I became limber. At the end of the class we had a few minutes of meditation to cool down. I don’t know what others were doing during that quiet time, me, I was planning the rest of my day. I think this is what most people experience at a Western style yoga class, nothing mystical or religious, no brainwashing. It’s just a feel-good, low impact physical workout.

      • SarahJ89

        I agree. It helps me relax in a very non-religious, non-spiritual way. How other people choose to use that time or this modality doesn’t affect me.

  • ninguem

    “…….Primary-care physicians are well-suited…….”

    Whenever I see an article with that headline, it means that whatever it is that primary care physicians are “well-suited” to do, is no longer paid by insurance.

    • SarahJ89

      Or it’s been left for them to do because no one else wants to do it.