Here’s what opioid guidelines fail to mention

Opioids have become so closely associated with chronic pain that it is nearly impossible to talk about one without the other. When we look back just five years ago, when we were still in residency, news stories about chronic pain and opioid overdoses were not commonplace. Now, we find ourselves almost desensitized to each new opioid headline. We are general internists, primary care providers and junior faculty. We practice at distinct locations, one at a Veterans Affairs medical center, the other at the associated academic medical center across town. Despite the various differences between our practices, we are both witnessing the same evolution of opioid prescription — the full impact of which neither one of us can predict.

For years the phrase “opioid epidemic” was thrown around by those in the medical field. Even with the plethora of chronic pain and opioid guidelines from states, professional organizations and agencies, it never seemed like the general public really understood the magnitude of the problem. When the CDC released their guideline for prescribing opioids for chronic pain in early 2016, the opioid issue finally seemed to register nationwide. Suddenly, there was a renewed and intensified focus on chronic pain and opioid use.

We get why guidelines and programs were made in response to the opioid crisis. And we understand that more changes are only inevitable. Yet, we cannot help but feel that every new recommendation or policy is essentially punishing providers (and subsequently patients) for prescribing opioids. In our state of Wisconsin, the HOPE Law recently went into effect, making it mandatory for providers to check the state drug monitoring program before prescribing all Schedule II-V controlled medications. One can imagine the response providers had to this new law. The law, we anticipate, will make providers think twice about whether opioids are really indicated and if so, whether their benefits outweigh the risks. It is, however, another time-consuming task providers are expected to somehow integrate into their practices.

Primary care providers shoulder an overwhelming amount of responsibility for what are viewed as “solutions” to the opioid epidemic, such as the HOPE Law. Not only are there just more PCPs compared to pain specialists, but many pain clinics focus on procedural interventions or make initial recommendations and send patients back to their primary for continued medication management.

In the community, the average PCP appointment is approximately 15 minutes. To address chronic pain, in addition to other medical conditions, counsel on prognosis, treatment options and medication side effects, on top of any acute concerns a patient might have, all within a 15-minute time frame seems laughable. But that is the challenge the majority of PCPs face on a daily basis. Some may argue that multiple visits with scoped agendas are the solution. The concern with this includes time, transportation and whether patients can afford to see their providers frequently. Not to mention scheduling and access issues on the providers’ end. However, possibly the biggest hurdle is that patients are often consumed by their chronic pain. The long-term consequences of uncontrolled diabetes or hypertension are not immediately tangible. But the pain that they are feeling is real and needs to be addressed before the end of the visit.

We were trained using evidence-based medicine, and it is something we strive to continue not only for our own practices but also to serve as role models for the next generation of physicians. As more research is conducted and our knowledge on medical conditions and treatments grow, what use to be the treatment for many conditions is no longer the case. A result of this is frequent, often involved, discussions with patients. Some do not understand why we won’t prescribe antibiotics for a viral URI when their prior previous doctor would always give them something. Or others cannot believe anything could be as effective as Vicodin for uncomplicated low back pain.

That is what guidelines fail to mention — the conversations providers have with patients. If simply adhering to guideline recommendations would make opioids safer for patients or the management of chronic pain more effective, we would like to think that most PCPs would find some way to be adherent. But that is what guidelines ignore. There is more to chronic pain management than ordering urine drug screens, initiating pain agreements and checking the state drug monitoring site. There is the humanistic side — the reason why many of us chose to go into medicine. This, we feel, is the most challenging and time consuming part of opioid management.

The conversations we have with patients about chronic pain and opioids often produce a series of strong emotions from both sides. While difficult discussions are not unique to chronic pain or primary care, pain is unlike so many other diagnoses that offer objective data to help make and support clinical decisions. It means nothing to a patient that their lumbar X-ray only showed “mild” degenerative disc disease. Their pain is still a 10 out of 10. There is also a negative stigma associated with chronic pain, which is not lost on patients. This can make having a productive conversation challenging, to say the least. In the end, after all of the history taking, physical exam maneuvers and imaging (if indicated), we have to decide if we believe our patient’s pain is real. And even if we were to operate under the assumption that all pain is real, then we must decide if opioids are indicated for that specific pain.

The patient-provider relationship is so important to perceived improvement, satisfaction and compliance. This is especially vital in primary care, as we manage the whole patient and not just a single condition. With pain, it can be a complicated feat to simultaneously convey belief, express empathy and explain why opioids are generally not indicated. We’ve certainly encountered a fair number of patients who were unhappy that we did not prescribe an antibiotic for their URI. But most of them do not accuse us of not caring or say that we want them to suffer. Our skin has gotten thicker over the years; but, it still stings nonetheless.

It is also draining to feel like we are constantly in a battle with our patients, trying to convince them that we really do have their best interest in mind and at heart. Sometimes it seems an impossible task to change patients’ perceptions of opioids. There is often a desire for an easy solution, a pill to fix the pain. The public is familiar with opioids. Less are aware of or knowledgeable about non-opioid options such as Duloxetine or Pregabalin and adjuvant treatments like pain psychology or procedural interventions.

Guidelines, checklists and clinical tools are helpful, but they fail to address what we feel may be the biggest challenge with chronic pain. It is a diagnosis whose complexity goes beyond prescribed medications, pain agreements, and drug screens and intricately involves the patient-provider relationship. Research, thus far, has generally focused on tangible interventions, such as drug tests and screening tools. Unfortunately, the most recent data from the CDC showed that overdose deaths from prescription opioids reached record numbers in 2014 and remain the leading cause of accidental death for the past two years.

Interventions beyond the provider level, such as policy change and increasing access to care, are likely necessary to adequately address the opioid situation. The patient-centered medical home (PCMH) model, which has been effective for the management of other chronic conditions like diabetes, has shown some promise in chronic pain. It is unclear, however, whether a PCMH model would improve opioid-related outcomes. Comprehensive pain programs have demonstrated effectiveness but require a significant amount of time, collaboration across fields and infrastructure that may be difficult to acquire for most practices and providers. Another area that should be addressed is patient education, specifically patients’ perspectives on opioids. As we’ve seen with antibiotics and URIs, it’s a long road to change patients’ perceptions and expectations. And it is likely more important than we imagine.

Maybe it is naïve to expect straightforward, simple answers. After all, this is a medical condition that has proven to be challenging in a number of ways. The country desperately needs solutions, and at this time, we are grasping for anything to help turn the tide.

The contents of this piece do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.

Cynthia Kay and Joanne Bernstein are internal medicine physicians.

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