In the face of the opioid crisis, change is afoot (read part 1: From a Doctor's Perspective). The American Academy of Pain Medicine and American Pain Institute acknowledges the stages of pain and the best use of medications. There now has to be an understanding of goals between patient and provider. This may involve a contract, where the patient agrees not to exceed a monthly amount of medications and to engage in other therapies to ultimately reduce dosages. There also has to be a risk assessment for addiction potential.
Identifying the potential for addiction can be as simple as asking: Is this a person whose day is centered around taking medications? Is there an obsession on the timing of the next dose of pain medication? Does the person spend the day avoiding activity because of the fear of pain? Is the person finishing the prescription and asking for earlier renewals or increased dosages?
Some Risk Mitigation Strategies:
- If the person has been on opioids for longer than the recommended period, start with an “opioid treatment agreement” and follow with drug testing.
- Avoid (or discontinue by weaning) tranquilizers being used in conjunction with opioids, since rebound anxiety adds to the sensation of pain.
- Use cognitive behavior therapy to modify behavior and eliminate catastrophic thinking that exacerbates pain.
- Introduce exercise to improve function and build self-confidence while learning to use the affected body parts.
- If necessary, refer the patient to a pain management specialist, who can utilize a broad formulary to help manage pain while weaning the patient either off the opioids/pain medications or at least reduce the frequency and dosage.
Nationwide, states have instituted a database and tracking system for pharmacists and prescribers to use so that these controlled medications are tracked by government agencies. In California, where I practice, the Controlled Substance Review and Evaluation System (CURES) was mandated in October of 2018. Every provider licensed to prescribe or dispense controlled substances has to be registered in CURES. Before prescribing or renewing a controlled substance you must enter the patient’s name to see if anyone else is already prescribing controlled substances to the patient. Using the database should give pause to the provider and consideration of other ways to manage chronic pain.
The most significant of all those measures is the realization that anyone who gets prescribed opioids for more than two successive months should be considered as having chronic pain. The provider must then demonstrate that he us using all the suggested measures of chronic pain management in an effort to limit use of potentially addictive drugs.
This program is administered by the U.S. Department of Justice (not by medical boards) so most doctors do not want to be identified as a provider who exceeds the two-month threshold. The CURES database tracks all scheduled II, III, and IV drugs, which include tranquilizers and sleep aids. That scope of drugs involves an entirely different patient population, who can also become addicted or dependent on drugs like Xanax, Ativan, and Ambien.
Since most primary care doctors are not pain specialists or trained extensively in psychology, providing adequate documentation and even having the skillset to manage these “chronic” patients is challenging and difficult.
The most likely outcome will be that most providers will choose to avoid treating these complicated patients. And if they send patients to the small number of pain management specialists, patients will struggle to book appointments and will face specialists who do not want to manage addicts, but rather prefer to dispense other therapies like injectables.
Will “addicted patients” facing these difficulties agree to work on weaning off these powerful pain medications, faced with these new challenges? Will doctors now limit use of powerful pain medications to a very short, three- to five-day time frame? Time will tell. Dentists and surgeons need to start rethinking their use of these drugs and screen patients carefully.
The ultimate goal is to begin to educate patients about potentially addictive drugs, and reduce or eliminate the use of the powerful medications by retraining patients to handle lower levels of pain. It’s clear that the medical community erred terribly with its “no pain” goal. It’s also clear that the pharmaceutical companies that developed these drugs may have not fully shared the addictive nature of these drugs. Ultimately patients and providers need to work as a team to have realistic expectations in pain management while making strides in measurable and meaningful improvements in function.