Results from a recent survey caught the eye of the Pain Reporter: only 25% of physicians who prescribe opioids feel confident in their ability to manage patients to whom they prescribe. Although 65% of those surveyed have attempted to improve their opioid prescribing practices, over 60% said that, due to time limitations, it wasn’t a priority. Read the Daily Dose, with links to the news release and survey results.
The survey was conducted by SCOPE—Safe and Competent Opioid Prescribing Education—at Boston University School of Medicine. Daniel Alford, MD, MPH, and SCOPE director, talks here about opioids, prescribing, and more.
Q. Do you think practitioners' self-perceived lack of opioid prescribing skills has changed how patients perceive opioid efficacy?
A. No, I don’t think patients are aware of practitioner’s lack of opioid prescribing skills. I think patients assume that providers have the knowledge and skills, but don’t prescribe for other reasons such as they either don’t believe the patient’s pain complaints, or they have an exaggerated fear of opioids causing addiction or an exaggerated fear of being scammed by patients who may be addicted or diverting or both. I also believe patients have an unrealistic perception of opioid efficacy. I think patients consider opioids to be better than they are. This leads patients to be overly focused on obtaining opioids, to request higher and higher doses, and to self-escalate doses in between visits.
Q. How has the teaching of opioid prescribing changed over the past few decades?
A. It has changed dramatically. We went from considering opioids only for acute pain and cancer-related chronic pain to considering it for all chronic pain. There was essentially a perfect storm when the Joint Commission, VA, and others began appropriately focusing on the need to universally assess and manage pain in all patients, while at the same time the pharmaceutical industry was marketing new extended release/long acting (ER/LA) opioids as a safer and more effective opioid choice to prescribe for treating chronic pain. This was before we appreciated how easy it was to misuse ER/LA opioids. The pendulum of opioid prescribing for chronic pain swung from underprescribing to overprescribing during this time period. The goal now is to swing back to the middle without going too far back to underprescribing.
Q. How would you like to see it taught?
A. Teaching should include more content on the complexities of chronic pain and how chronic pain is more than just a symptom (eg, acute pain) but more like a chronic disease that is multidimensional and requires multimodal care. Overreliance on a single medication, such as opioids, for a complicated complete chronic disease (eg, chronic pain) is bound to fail. Use of opioids should be taught using a balanced approach. Opioids are just one of numerous imperfect tools for managing chronic pain. Opioids are not all good and they are not all bad. I believe there is a role for chronic opioids for some patients with severe chronic pain but they need to be prescribed with extreme caution and prescribed along with other modalities of pain care, such as self-care, physical therapy, cognitive behavioral therapy, or acupuncture.
Opioids for chronic pain should be prescribed using the same risk-benefit framework that we use for all medications prescribed for chronic diseases. That is, when on opioids, is the patient obtaining more benefit than harm—improvements in pain, functional and quality of life improvement vs adverse effects or signs suggestive of addiction. If there is too much risk, don’t prescribe. If there is apparent harm, stop prescribing. If there is adequate benefit in the absence of harm, continue prescribing. It is also important to teach that stopping opioids due to lack of benefit or too much risk is not abandoning the patient, it is abandoning either an ineffective or harmful medication. We need to continue trying to manage the patient’s pain with nonopioid strategies.
Q. What methods work best for you as a professor of medicine?
A. As stated above, to frame it similar to other chronic diseases that I manage. That is, do the benefits of the treatment (eg, opioids) outweigh the risks or harms? The problem is that, unlike many other treatments and diseases (e.g., hypertension, diabetes) that I manage in medicine which have objective outcomes, both the benefits and harms associated with opioids for chronic pain are subjective. The other problem is the lack of scientific evidence supporting the use of long-term opioids for chronic pain. While we would all like more evidence to support this practice, we need to remember that it is an absence of evidence rather than evidence of absence. In primary care we understand this difference and are accustomed to making clinical decisions based on individual patient’s response to a specific therapy.
Q. Has your background in addiction and abuse influenced how you teach medicine?
A. Yes, it has given me an appreciation of the risks of opioids. However, I would say that being both a primary care physician who manages patients with chronic pain and an addiction medicine specialist who manages patients with opioid addiction, I appreciate both the potential benefits and the potential risks of opioid prescribing.
Q. Do you think the state of opioid prescribing is improving?
A. Hard to say. Based on national data sources there seems to be decreased overall prescribing but I’m not sure what that means. It is unclear if that means that patients who are not improving or who are misusing opioids are being taken off them, or that patients who are benefiting from opioids are being taken off them, or more likely a combination of both. I do think there are fewer “30 day” prescriptions for postop acute pain or dental pain, which is a good thing.
Q. What is a dream project you hope to work on?
A. I am working on my dream project: Educating my colleagues how to safely and competently prescribe opioids for patients suffering from chronic pain. I feel that I am empowering providers to make sound clinical decisions regarding starting, continuing, modifying, or discontinuing opioids based on their clinical observations and at the same time maintaining access to opioids for patients with chronic pain who are benefiting from them.
Thank you, Dr. Alford, for both your interesting study and for taking the time to answer our questions.
Be sure to check out the painweek.org library of articles on opioids.