May 4, 2011
Course-correcting how doctors treat chronic pain
Related article: COPE online education responds to FDA call for safe prescribing of pain killers
Dr. David Tauben is a primary-care physician and board-certified pain-medicine specialist with UW Medicines Center for Pain Relief. He discussed pain care trends and Washington State House Bill 2876, signed into law last year, which dictates new dosing criteria for non-cancer pain management, starting in July. The following Q & A with Tauben is republished from Consult, a UW Medicine periodical for physicians in the WWAMI region of Washington, Wyoming, Alaska, Montana and Idaho.
Q. Describe the trend in the past decade of physicians managing patients pain.
A. The number of patients receiving very high-dose opioids has gone up dramatically but it hasnt reduced the number who struggle with chronic pain. Opioid prescribing has become enormously controversial.
Q. What changed?
A. Its complicated. Simply put, the model for acute and cancer care has been extrapolated to chronic, non-cancer care. Frankly, this has been a large-scale experiment but nonethelessbased on compassion and strong patient advocacy,and done conscientiously. The problem is that the transition to higher doses has become a very serious problem, with more than 5,000 people dying per year in the United States of unintentional opioid overdose. Data conclusively tells us that giving these high-dose opioids long-term is riskier than we all had anticipated, myself included.
A. More than three months of continuous daily opioid intake.
Q. And the cancer-pain care model doesnt have broader application?
A. Physicians were under the impression that, as dose increased, efficacy followed. Instead, we have found that the benefits of dose-increase level off at fairly conservative values and, even more surprisingly, as the dose becomes higher, people develop an opioid-associated hyperalgesia –an increase of pain – rather than analgesia
Q. How do physicians discern a patients threshold of benefit? Is a dosage limit spelled out?
A. The best data available suggests 40-100 milligrams of morphine equivalent represents the highest daily doses that most patients should require. If a patient requires above that, the risk-benefit balance starts to shift heavily toward risk, and referral to a pain specialist is appropriate.
Q. Has opioid prescription become a too-quick first response to patients with pain?
A. Opioids are appropriate first-line therapies for acute pain.For chronic pain, though, the overwhelming consensus among pain experts is that opioids should never be the sole therapy. When they are, adverse outcomes are more likely.
Q. Before it became law, Washington States proposed opioid-prescription regulation drew vocal opposition from a physicians group. What do you make of that?
A. Doctors do not want to be told by legislators how to take care of patients, so the immediate response was negative. As the specifics were clarified, though, there has been broad consensus that this is much-needed reform. The law is going to allow primary care doctors a greater ease and get more primary care doctors willing to prescribe opioids rather than less.
Q. Didnt you say the trend had been greater opioid prescription?
A. All these accidental overdoses have received lots of news coverage. The New York Times had a story asking, “Is this a pain doctor or a drug pusher?” Conscientious doctors started to say,”I dont want any part of this.” Now many doctors offices have signs saying “No opioid prescriptions” because thats the easy way out. This bill is designed to turn that around. Were trying to thaw the climate, add some reason, some science, provide the education, the skills to take care of pain.
Q. Does this law remind physicians to check whatever biases they might have?
A. The word “check” is good. Imagine if you went to see your doctor about possible high blood pressure and the doctor gave you medication and never checked your blood pressure. Youd have good cause to find a more competent doctor. We are asking primary-care doctors who take care of pain to check the patients pain intensity, function, mood and risk. Moreover, we are providing doctors tools that have been validated to do those checks.
Q. But doesnt the additional Q&A take more time than traditional office visits?
A. Yes. The pressure on doctors is to get to the next patient and not get hung up on challenges that chronic opioid therapy entails. Writing opioid prescriptions is a quick way to end the interview and move on. By having the tools at hand, the passport to the next patient does not have to be more opioids. It can be, “Lets talk about other strategies, or your physical therapy session that wasnt effective, or risks that you may not be aware of.” Once we become skilled at having this conversation and using these tools, we become more efficient and better communicators.
Q. Patients have to buy into this mindset, too.
A. Patients need to be willing to have this conversation and not presume, “My doctor doesnt want to take care of me with the best treatment.” They need to be included in this dialogue, to be told of the significant health risks of high-dose opioids, and to be more engaged in their health.
Q. Whats UW Medicines value to the community in treating pain?
A. UW Medicine has introduced measurement-based tools that primary-care and other providers can use in caring for patients with chronic pain. We offer weekly live video consultations with providers throughout the WWAMI region. In parallel, were working with the Department of Defense to improve pain management for soldiers returning totheir communities.