Appropriately assessing and treating people with moderate to severe acute and chronic pain continues to be a significant and ongoing problem in the United States. Primary care providers (PCPs) are on the front lines of this battle, navigating how best to diagnose pain, manage patients, and incorporate the Centers for Disease Control and Prevention (CDC) guideline into their practice. However, growing concern from PCPs about the guideline, public and professional scrutiny, and potential repercussions have started to affect patients’ ability to receive adequate care.
It is imperative that immediate steps are taken to better educate and engage PCPs – helping them to not only properly integrate guidelines into their practice, but to also improve pain assessment, align appropriate treatment with diagnoses, and feel more comfortable helping those living with pain. And while opioids can be an effective and necessary treatment option, PCPs must better understand how to properly utilize them.
Equipping PCPs with tools and information that allow them to become invested in managing chronic pain has emerged as the best path forward to appropriately address the needs of patients in an effective and meaningful way.
Scrutiny and Fear Impacting Patient Care
Back pain is one the most common reasons individuals seek medical attention today,[i] with PCPs often being a patient’s first stop. Today, more than ever, those of us working in primary care face an increasing number of challenges in diagnosing and treating people living with pain, including the stress in managing these patients, concerns about medication misuse and abuse, and insufficient training in pain management and proper prescribing.[ii]
These obstacles are compounded by ongoing public discourse about pain treatments, which focuses almost solely on opioid abuse; you can see these discussions play out in news stories and on the political stage. It has caused many PCPs to worry about not only professional or public criticism, but legal actions as well, further threatening patient care.
Combined with recent government guidelines and regulations, these pressures are resulting in PCPs avoiding treating those in chronic pain, often referring them instead to pain specialists. Others have started to modify how they address pain, some decreasing or stopping prescriptions and dosages to the point of leaving patients living with continued pain.
At first blush, it may seem like a positive for more people to be referred to pain specialists and for fewer opioids to be prescribed, but this doesn’t take into account the full picture. First, in many regions, pain specialists are few and far between, and they are now receiving an influx of patients without the resources to manage them. Additionally, people living with pain have legitimate needs and alternative treatments may not be effective, with opioids being the best course of treatment in certain cases.
Confusion and Misinformation around CDC Guideline
Earlier this year, the CDC released the Guideline for Prescribing Opioids for Chronic Pain, providing recommendations for prescribing opioids to chronic pain patients in primary care settings. The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use. While well-intentioned, it is causing confusion, and in some cases, preventing patients from being treated appropriately.
Overall, the guideline aligns with many of the best clinical practices we have been employing for years. For example, several recommendations focus on improved communication with patients, including through establishment of treatment goals and discussions around known risks and benefits.
Others are more concerning and may contradict clinical judgement. For example, one recommendation advises always starting patients with immediate-release/short-acting opioids (SAOs) instead of extended-release/long-acting opioids (LAOs) for treating chronic pain. In some instances, this may be the most appropriate route. However, this oversimplifies a complex issue and can result in patients being treated with SAOs for “pro re nata” (PRN) analgesia for chronic, round-the clock pain. Undertreating this condition can result in patients being prescribed higher doses of LAOs if they are later switched as a result of worsening, severe, persistent and/or chronic pain not adequately managed.
Another recommendation focuses on always prescribing the lowest effective dosage based on morphine milligram equivalents (MME), a measurement calculated from the degree of mu receptor agonist activity. However, not all opioids are the same. The pharmaceutical industry has introduced next-generation molecules with new potential mechanisms of action that have lesser activity on mu receptors and simultaneously work on neuropathways, but have a similar analgesic effect to traditional/older opioids. These molecules work on both ascending and descending pathways, and should not be characterized in the same way as medications that are solely mu receptor agonists.
While efforts to provide primary care direction that supports responsible and appropriate prescribing, it is important to note that the guidelines do not recommend elimination of opioids entirely. The bottom line is that PCPs can and should consider opioids for appropriate patients, taking steps to thoroughly diagnose, review risks and benefits, and identify the therapeutic options best suited for each individualized case.
Targeted Education and Engagement of PCPs
When we decided to become PCPs, most of us did not sign up to be pain specialists. However, our patients are coming to us to help relieve their pain. There is little doubt that something needs to change if we are going to appropriately and adequately help those living with chronic pain. We need to address gaps preventing access to patient care, while working to minimize abuse in today’s highly-regulated environment.
Perhaps the best solution has always been right in front of us: taking immediate steps to better educate PCPs around identifying, assessing and treating pain, while making them more engaged and comfortable aligning diagnoses with treatment. We need funding and access to better training, as well as practical tools that may be used in a busy practice to help with assessing people in pain.
I recently participated in a discussion with leading experts in the pain space on how we can do this together. One of my colleagues noted that we need to inspire PCPs, making them feel like heroes instead of villains, all while keeping them interested in addressing the needs of their patients despite the challenges.
We know that changing attitudes through expanded and enhanced education will not be easy – it will take a significant investment from healthcare providers, professional organizations, legislative bodies and pharmaceutical companies. We must all commit to becoming properly equipped with educational tools and more information that helps us get invested and excited about helping our patients manage chronic pain.
While misuse of opioids is certainly an issue that many people are working to address, moderate to severe acute pain and chronic pain continue to be inadequately managed, a problem that is not going away. And as treating pain becomes more of a challenge for those of us fighting on the front lines, as we work to balance helping patients to live full, productive and happy lives with regulatory and professional guidelines and concerns, we must do everything we can to ensure we leave no patient behind.
Dr. Steve Vacalis is a board-certified family medicine physician affiliated with CaroMont Family Medicine in Gastonia, North Carolina. He has been in practice almost 20 years, treating a broad range of patients including those with acute and chronic pain, using osteopathic manipulative therapy as an adjuvant option when needed. He specializes in diabetic, cardiovascular, and preventative medicine, as well as sports health and pain management. Dr. Vacalis previously served as chairman of the Department of Family Medicine at CaroMont Regional Medical Center. He graduated from the Des Moines University College of Osteopathic Medicine in 1996.
Dr. Vacalis is a paid consultant for Depomed, Inc., which sponsored development of this piece.
Readings & Resources (click to view)
[i] St. Sauver, Jennifer L. et al. Why Patients Visit Their Doctors: Assessing the Most Prevalent Conditions in a Defined American Population. Mayo Clinic Proceedings, Volume 88 , Issue 1, 56 – 67.
[ii] Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.