Monday, January 29, 2018

What's new in opioid prescribing, treatment, and education?

- Jennifer Middleton, MD, MPH

Coverage regarding the opioid epidemic shows no sign of slowing, and a flurry of articles this month -- 5 articles across 4 different Family Medicine journals -- bring several important insights and tools for family physicians to consider incorporating into their practices.

The first is an editorial published online in AFP this past week on "Treating Opioid Use Disorder as a Family Physician: Taking the Next Step." The editorial reviews 12 different models for providing buprenorphine-based medication assisted therapy (MAT) for opioid addiction in a primary care office, including outpatient models, inpatient models, and models that both do and don't incorporate behavioral counseling. Project ECHO is one model that may appeal to rural physicians, as it connects physicians interested in providing this treatment with experts via the internet. The editorial also includes a table with several valuable resources for physicians providing MAT, including the American Society of Addiction Medicine's website which has a wealth of resources for both physicians and patients.

A cross-sectional study regarding "Prescription Opioid Use and Satisfaction with Care Among Adults with Musculoskeletal Conditions" in the Annals of Family Medicine found greater satisfaction associated with prescription opioid use. The authors examined 6 years of data from the Medical Expenditure Panel Survey for adults with documented musculoskeletal diagnoses; patients receiving prescription opioid medications had higher patient satisfaction scores than those not receiving opioids (odds ratio = 1.32; 95% confidence interval, 1.18–1.49). The authors found that patients taking opioids reported more pain and greater disability, however, than those not taking opioids and cautioned that:
"The lack of an association between opioid prescribing and improvements in pain on a population health level has been highlighted by the Centers for Disease Control and Prevention, who report that since 1999, the quantity of prescription opioids sold in the United States has almost quadrupled, yet there has not been an overall change in the amount of pain that Americans actually report."
Two articles examining office-based strategies for managing patients on chronic opioids in the Journal of the American Board of Family Medicine each share interesting insights. "Structured Management of Chronic Nonmalignant Pain with Opioids in a Rural Primary Care Office" describes a rigorous office process required of all patients receiving chronic opioid prescriptions, including administration of several validated scales at each visit (Brief Pain Inventory Short Form, Zung depression scale, SOAPP-R diversion risk assessment tool, and the Roland disability rating scale for back pain), a standard patient handout describing opioid risks, and a standardized documentation template. This approach increased compliance with state and federal opioid prescribing regulations and also decreased the total number of opioid prescriptions written by their office. "Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety" found that adding a pharmacist previsit to appointments for chronic pain decreased overall opioid prescribing with no change in reported patient pain scores.

Finally, from the Society of Teachers of Family Medicine's Family Medicine journal comes "Teaching Chronic Pain in the Family Medicine Residency," a cross-sectional survey of Family Medicine residency program directors about their program's curricula regarding chronic pain. With a 53% response rate of program directors from across the United States, they found that an average of 33 hours (with a wide range of 2-180 hours across programs) of curricular time is devoted to teaching about chronic pain in Family Medicine residencies. The authors hypothesized that residency programs with directors who had negative attitudes about chronic pain and/or MAT would provide less education on these subjects, but this hypothesis was not borne out in their findings; the only predictor of higher curricular time, interestingly, was a strong belief in the benefit of nonopioid treatments for chronic pain. The wide range of curricular hours across the US suggests that residency programs have some work to do to validate and standardize effective teaching on this important subject.

Which of these ideas and/or tools will you consider incorporating into your own practice? Or, perhaps, you have a different model of success to share with AFP readers; we welcome your comments below.