- Kenny Lin, MD
For years, family physicians who treat patients with chronic nonterminal pain have been caught between a rock and a hard place: national surveys show that chronic pain is undertreated, but opioids often have serious adverse effects and can lead to dependence, addiction, and abuse. A recent AFP review article advised comprehensive assessments for patients with chronic pain, careful patient selection using an opioid risk tool, and use of written agreements that "outline appropriate intervals for follow-up, refill policies, participation in any indicated multimodal management plan (e.g., physical therapy, psychological treatment), use of only one prescriber and one pharmacy for all controlled medications, and prohibition of illicit substance use or prescription diversion." In July, the U.S. Food and Drug Administration, in consultation with the AAFP, required that manufacturers of prescription opioids pay to support new voluntary educational programs for clinicians and patient education materials designed to reduce opioid misuse and its consequences.
An editorial in this week's Archives of Internal Medicine questioned whether there is a true difference between opioid "dependence" and "addiction," noting that a Washington state law that limited the amount of opioid that can be prescribed for chronic pain led to many patients experiencing persistent withdrawal effects after being tapered to lower doses. The authors concluded: "Dependence on opioid pain treatment is not, as we once believed, easily reversible; it is a complex physical and psychological state that may require therapy similar to addiction treatment, consisting of structure, monitoring, and counseling, and possibly continued prescription of opioid agonists." What has been your experience in prescribing opioids for patients with chronic nonterminal pain?
Wednesday, August 22, 2012
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Interesting and "charged" issue. My experience based on my years of practice are that YES: i) Narcotics are addictive, overused and inappropriately used - as well as overprescribed. This is especially true for non-cancer chronic pain. ii) New emphasis on revising policy in effort to reduce inappropriate use of narcotics have clearly been effective. That said - in my opinion - the result of recent revisions in prescribing policy is that fewer and fewer non-pain-specialist primary care physicians are currently still prescribing longterm narcotics for non-cancer pain.
ReplyDeleteMy impression of the overall result of the above is positive: i) It becomes far easier for the primary care physician if he/she doesn't have to worry about having to prescribe longterm narcotics for non-cancer pain - and ii) the amount of inappropriate prescribing clearly goes down. That said - I firmly believe that there IS a certain population of individuals with non-cancer pain who have benefited in the past from longterm narcotics without abuse. Many of these unfortunate patients no longer are able to get relief of their symptoms. They are "cut out" of what may have been for them a valid therapeutic intervention that treated their chronic pain that had not previously been relieved by other measures.
Potential problems are the following: YES - such patients are now being referred to Pain Clinics. But (depending on the community) - Pain Clinic referral may or may not be a reality (either due to financial limitations or lack of enough pain doctors to go around). YES - it would be far better if other modalties, therapeutic approaches and non-narcotic pharmaceutical approaches could control their chronic pain. Sometimes it will - but sometimes it won't. And flagrant increase of NSAID prescription (in my opinion) holds potential of far worse complications than judicious use of longterm narcotics in patients regularly followed by a primary care clinician convinced that the patient is not abusing this script. The BOTTOM LINE that I've observed in my area - is that many (most) Pain Doctors no longer even consider longterm prescription of narcotics. They don't know the patients. They don't trust the patients. Their clinics are overfilled. They often don't believe the patients because they do not have a longterm primary care relationship that may have been nurtured over several decades ...
I'll close by emphasizing that my life as a practicing phsyician (as well as teacher of family medicine) was made much easier in my last years of practice by simply telling patients, "I can no longer prescribe chronic narcotics for your non-cancer pain". I know overall that doing so clearly cut down on abuse and inappropriate use of narcotics by many patients. But in my own experience - I also know of more than a few cases in which I as longterm family physician was utterly convinced that patients who had finally attained control of their chronic noncancer pain and were not abusing narcotics were now abruptly cut off from receiving these medications, and as a result were no longer able to attain comparable pain relief by this "new policy" ... To me- that is a shame.
Excellent comments above. I entered a few of my thoughts on the topic in a blog entry:
ReplyDeletehttp://patientssaythedarndestthings.blogspot.com/2012/08/confession-of-narcotic-over-prescriber.html
I experience withdrawal on a daily basis, with Oxycontin for around 3 hours immediately before my next dosage. im upto 120mg a day at the moment. I would like to stop taking it and switch to something else, the issues for me this this are:
ReplyDelete1) my Doctor is not comfortable changing my medication, increasing it or suggesting an alternative and contantly tried to pass me over to the pain management clinic which ive waited for over 7 months not for an appointment.
2) the effects of withdrawal are frightening to me. i really dont know if i could bear it , putting up with increased pain leves at the same time.
Ive written a lot over the last few days on Oxycontin if you are interested.
you can find it at
www.AndPain.Com
Best Regards
Tommy