By Terri Lewis, PhD, Guest Columnist
The recent issuance of draft guidelines for opioid prescribing by the Centers for Disease Control and Prevention (CDC) posits some troubling guidelines for physicians – troubling because they prioritize the practice of prescribing over the treatment of patients. They infer that the use of opioids is tantamount to the onset of addiction and equate dosing levels with metrics unrelated to a patient resuming activities of daily living.
To ignore the individual patient’s needs in favor of applied population modeling for prescription overdose is tantamount to the institutionalization of malpractice and violates the very tenets of person-centered health care.
Physicians are moving to an environment that will redefine and reclassify conditions associated with chronic pain based on a body systems approach. In the arena of musculoskeletal systems alone, there are 99 classifications associated with pain levels that range from acute to chronic to intractable. All have the potential to require lifetime treatment at levels beyond those associated with acute pain.
Medicating a person so that the impairment imposed by acute pain does not convert to chronic pain or disability is a very important concept in our health care decisions – both as providers and as consumers. While long term opioid prescribing may have negative implications for some, this is largely a failure of models of care and not a failure of consumer utilization.
A review of death and injury data maintained by the CDC indicates that prescription drug overdose is not even in the top 15 leading causes of death in the U.S. The number of overdoses that occur in the population annually should not be the primary filter through which we consider the needs of persons with chronic pain.
The third largest measured harm to patients is associated with care by a physician or hospital – conditions over which patients have no control and which can result in lifetime injury. Wrong diagnosis, wrong prescribing, failure to rescue, hospital acquired infections, improper surgeries and other forms of malpractice all create conditions of significant injury that can lead to chronic pain. Far more risk to the patient is associated with covering up harmful industry practices and the institutionalization of biases that opiod treatment causes addiction. Correlation is not causation.
Before starting long term opioid therapy, providers should establish treatment goals with all patients, including realistic goals for aftercare, restoration of functional activities, and pain reduction. No medication, including opioids, should be prescribed unless it is for conditions for which it was clinically trialed, or when there is clinically meaningful improvement in pain reduction and function that outweighs risks to patient safety.
Before starting any therapy, providers should discuss with patients risks, limitations, and realistic benefits of opioid therapy, as well as the patient’s and provider’s responsibilities for managing that therapy. A careful history, an understanding of the context to which the patient will operate, the supportive resources available, and the daily demands upon their independence and functioning, are critical indicators for monitoring performance that have far more important meaning than dose limitations.
The important question is not whether opioids are contraindicated by regulation, but whether opioids are likely to return the patient to a state of functional behavior or have a role in helping them maintain their independence and daily activities.
When opioids are started, providers should prescribe the dose that is most likely to benefit the patient. For some, this will be a very low dose, but for others it may take more due to conditions associated with their personal genetic characteristics. Patients can build a tolerance to low dose medications when they are prescribed doses that do not alleviate pain. Rather than being afraid to over-medicate, we should be just as concerned about the impact of under-medication in building tolerance.
The CDC’s recommendation that 3 days or less supply of prescribed opioids for non-traumatic acute pain may well fall short of individual needs.
Providers should evaluate patients frequently when starting long-term opioid, anti-epileptic, or anti-psychotic drugs alone or in combination. Evaluation should include serum levels, behavioral observations, assessment of adaptive behavior and progress toward adaptive functioning.
Patient contracts are ethically troublesome and tantamount to withholding medications based on characteristics or behaviors that may have nothing to do with patient outcomes. It is unethical to hold a person in chronic pain hostage to the withholding of effective treatment, and many believe this should not be the basis for informed consent conversations. These conversations frequently occur within the first or second doctor visit, when little is understood about the patient, their condition, its causation, or direction for treatment.
Another one of the CDC’s recommendations is for urine drug testing of patients on long term opioid therapy. Urinalysis often falls far short as a metric for adherence and compliance with a prescribing routine. Differences in individual rates of metabolism may well cause providers to make errors of judgment when analyzing drug test results. Many urine tests have significant rates of poor performance, physicians may not understand the potential for false positives and negatives, and some labs fail to employ procedures that are consistent.
These tests also have the potential to add many hundreds of dollars to the patient’s bill, a cost for which they cannot be reimbursed on many insurance plans. Failing a drug test may unnecessarily stigmatize the patient and impair the treating relationship.
Risks and Benefits of Opioids
When the benefits might not outweigh harms of continued long term opioid therapy, providers should work with patients to periodically evaluate dosing, add other non-pharmacological therapy and, if possible, discontinue opioids when treatment so indicates.
All patients are not equally vulnerable. Before starting, and periodically during continuation of opioid therapy, providers should incorporate into the management plan strategies to mitigate risk, including patient and family education, gathering of information about the impact of the health condition on long term function and independence, interaction with other medications or foods, and rescue support if indicated.
Most providers are now required to review the patient’s history of controlled substance prescriptions by using prescription drug monitoring databases to determine whether the patient has access to excessive opioid dosages or dangerous combinations of medications. Used properly, this is an effective tool. But it is important for providers to understand that this data itself has limitations and may be biased by the availability of medications, prescriber behavior practices, and pharmacy filling practices.
Many a user has been accused of abuse for data that reflects limitations that have nothing to do with the patient. Providers should be very careful about drawing conclusions and should balance this information with other indicators – patient reports, community supports, consumer functioning, and so forth.
It is important to understand that persons with chronic pain are, by their very nature, patients with complex care needs who have injuries to multiple body systems. Chronic pain is a total body experience, no matter the origin of the injury or illness. The person is not going to be “cured” and cure is not the treatment goal. Returning the person to the best function possible is the goal, along with assuring them that you will be a partner in helping them achieve a quality of life through treatment they can depend on.
We have to change our thinking about approaches that require us to treat to the dose, and stop interpreting this issue of pain care within the acute care model. Those who would divert us from this goal are not leading the public conversation toward an effective national pain strategy.
Terri Lewis, PhD, is a specialist in Rehabilitation practice and teaches in the field of Allied Health. She is the daughter and mother of persons who have lived with chronic pain.
The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.