Let’s Face It–Some Patients Need to Be on Opioids

Let’s Face It–Some Patients Need to Be on Opioids – medscape.com – Kenneth W. Lin, MD, MPH – Feb 2019

According to a National Institutes of Health–sponsored workshop, an estimated 25 million Americans experience moderate to severe chronic pain, and 5-8 million of them use opioids for long-term pain management.

Although it is now widely recognized that excessive opioid prescribing has contributed to an epidemic of opioid use disorder and overdoses, the adoption of inflexible dosing limits or “no opioid” policies by many physicians and pharmacy benefit managers has also caused substantial harm.

Last November, the American Medical Association’s House of Delegates adopted several resolutions that advocated against misapplication of the 2016 CDC guideline on opioids for chronic pain.

So far, there have been no changes, despite the FDA’s and the CDC’s warnings about minterpretation of the guidelines. 

An international group of pain experts recently called for “an urgent review of mandated opioid tapering policies for outpatients at every level of health care … to minimize the iatrogenic harm that ensues from aggressive opioid tapering policies.“

My clinical experience and a recent systematic review convince me that selected patients with chronic non-cancer pain receive more benefit than harm on opioid therapy.

And this is what too many are forgetting: when opioids are effective for a pain patient, they provide much more benefit than harm.

An ongoing challenge in my practice is inheriting patients on chronic opioid therapy whose previous physicians have retired or stopped prescribing.

If this applies to you, please do your patients a favor and facilitate their care transitions by documenting their

• chronic pain diagnoses,
• comorbid physical and mental health conditions,
• acute pain triggers,
• other pharmacologic and nonpharmacologic interventions that have or have not helped, and
• the rationale for past increases or decreases in opioid dosing

In their draft report on pain management best practices, an interagency task force convened by the Department of Health and Human Services recommends that care for these patients be balanced, individualized, and include multiple modalities such as interventional procedures, physical therapy, integrative medicine, and behavioral health if indicated.

It recommends that Medicare, Medicaid, and private insurers pay for effective nonpharmacologic pain therapies and reimburse primary care clinicians adequately for the time and resources required to manage patients with chronic pain.

The draft report reiterates the limitations of the CDC opioid prescribing guideline and states that legislation or payer requirements for a one-size-fits-all approach to acute or chronic pain are inappropriate and potentially harmful.

For example, although care teams should access PDMP data periodically, making it mandatory to check the PDMP prior to every single interaction involving an opioid prescription creates unnecessary burdens for practices.

Finally, the report discourages healthcare professionals and the general public from stigmatizing patients with chronic pain “as people seeking medications to misuse.”

It’s a bit late for that. We pain patients are considered addicted to our opioid pain relief.

The anti-opioid zealots believe anyone who takes opioids for several months is addicted. They fervently believe that we crave opioids “to get high” or “prevent withdrawal” because they refuse to consider that it’s our chronic pain that makes us “drug-seeking”.

In all the talk about opioids, especially the milligram amounts, no one seems to remember that there’s a reason we’re taking this medication. So many studies try to corellate various situations with opioid milligrams. This is like trying to reduce insulin doses without considering what the insulin is taken for.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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