Practitioners have been outspoken in describing how they feel a lack of confidence in their own abilities to use opioids, in who to use them, and how to use them. If you couple that with their lack of knowledge about the alternatives to opioids, you really have a situation that is bound to fail because you won’t have the capability to tailor treatment to the individual patient. When you think about who you’re going to be prescribing opioids to, of course there’s going to be legitimate patients and there are going to be other patients that don’t do as well--the person who’s noncompliant or a high utilizer of healthcare or even very demanding of your services in a way that makes you feel out of control in the care of that patient. We’ve learned that opioids are not the panacea and that the eradication of pain is in most cases impossible, and certainly not the only goal. While it would be nice to have people pain-free, what we’re really faced with is helping people to be functional despite some level of pain. We all have a variety of physical burdens that we have to struggle with each day, particularly as we all get older, and yet most of us are able to remain functional in ways that are satisfying. So, in prescribing whatever medication, the practitioner now has to ask if the patient more functional than they were before that medication; and if they’re not, then they need to think about whether the medicine should be changed, or whether other therapies should be engaged.
I think the clinical community should recognize that opioids have been overused and have not been used in a precise manner. As a result, society and its regulatory agencies are now scrutinizing us and starting to limit our ability to care for our patients in the way we might want to. Guidelines have many problems, in part because they really can’t offer the specificity for how to manage an individual patient. They are general, and they are meant to be broad. They serve a role in terms of helping to educate providers, but they fail us when they then are used to constrain our ability to practice and to treat the individual patient. So, I think clinicians and others related to healthcare delivery have to do a couple of things. They really do have to focus on what are the alternatives to opioids so that they have more in their armamentarium, and they also have to become more vocal and demand that we retain the ability to practice and take care of our patients in ways that we control and oversee. We should be trying to make the case to insurers and other payers in our system that some of the best evidence for treatment of chronic pain is multidisciplinary care, non-medication therapies and coordinated care. All of which the health insurer or payer should be interested in because ultimately if the patient has a better outcome, the cost of care will be less.
When you’re thinking about how to create a coherent system of care, you do want some top-down influence. You want some regulations, you want some oversight, you want there to be mechanisms to address the public concerns and the epidemiology of patient care. But you can never forget that patient care really is a one-on-one enterprise; it’s a practitioner and their patient.