The Changing Face of Pain Management: Patients, Opioids, and the Law

BY VICKI RITTERBAND
VITAL SIGNS STAFF WRITER

Richard Pieters, M.D.
Richard Pieters, M.D.

As a radiation oncologist, MMS President Richard Pieters, M.D., knows the many faces of cancer pain: the grinding back pain of pancreatic cancer, the piercing pain when tumors obstruct the bowels, the persistent pain of bone metastasis.

But increasingly, patients are coming to him with severe pain that’s being managed by their primary care physicians with nonsteroidal anti-inflammatory drugs. “The drugs haven’t touched their pain,” said Dr. Pieters, who applauds the state’s recent efforts to confront the opioid addiction epidemic, but worries about the pendulum swinging too far in the opposite direction. “My bottom line is when a patient is dying, they must have the medication they need. Let me take care of my patient.”

It’s a delicate balance: the need to adequately quell pain with powerful and sometimes addictive opioids versus the risk of these medications being diverted and abused and the public health crisis that ensues. Massachusetts and other states have seen a dramatic surge in unintentional opioid deaths in the past decade. In the Bay State, fatal opioid overdoses increased by 90 percent from 2000 to 2013, and nationwide these analgesics have become the leading cause of accidental death.

‘Dramatic Course Correction’

It is not surprising that there’s been a dramatic course correction in governmental and medical circles. Last month, the U.S. Drug Enforcement Administration reclassified hydrocodone combination products, the most commonly prescribed medication, as Schedule II medications — those with the highest potential for abuse and harm.

Closer to home, the DPH is considering changes to its Prescription Monitoring Program and expanding community and residential treatment services for underserved populations. Increasing numbers of Massachusetts police and firefighters are now trained to administer naloxone to reverse opioid overdoses. The MMS will soon have representation on a new state commission tasked with recommending best practices for insurers to combat the opioid addiction crisis, including prior authorization requirements, refill restrictions, and data collection practices.

The Physician’s New Role

Where do physicians fit into these efforts? Vital Signs asked several MMS members how physicians can help stem the opioid addiction problem. Their answers ranged from viewing opioid prescribing through a risk-versus-benefit analysis to becoming better informed about pain management and medication-assisted therapies to teaching patients about proper drug disposal.

Jessie Gaeta, MD
Jessie Gaeta, M.D.

For years, Jessie Gaeta, M.D., medical director of Boston Health Care for the Homeless Program, has seen the devastation of opioid addiction among the homeless. A 2013 study by her program and Massachusetts General Hospital showed that drug overdose was the leading cause of death among homeless adults in Boston from 2003 to 2008, overtaking HIV, the top killer in the late 1980s and early 1990s.

“When I think back on my own medical education in the mid-to-late 1990s, what was missing from the conversation was how to approach decision making about opiate prescribing — how to think about the risk versus the benefits,” she said. “While I still prescribe opiates, I’ve become more focused on a benefit-to-harm framework — considering the risk of prescribing while understanding the disparity in chronic pain that homeless people experience.”

Dr. Gaeta also believes that more physicians — and not just those who care for the underserved — need to be trained in medication therapies like methadone, naltrexone, and buprenorphine (Suboxone).

MMS OFFERS SEVERAL ONLINE CME-ELIGIBLE COURSES ON ADDICTION AND OPIOID PRESCRIBING, INCLUDING THE FOLLOWING:


“Very few people with opiate dependence have access to these therapies,” said Dr. Gaeta, whose organization has a robust and successful Suboxone program that needs to grow further to keep up with demand. She understands physician reluctance to treat addicts, who can be very difficult patients, but faults some in the medical community for still regarding addiction as a behavioral issue. “There is a neurobiology that is more and more understood, yet many still do not view addiction through the lens of chronic disease,” said Dr. Gaeta.

MMS President-Elect Dennis Dimitri, M.D., is an advocate of bringing more addiction treatment into physicians’ offices, which will encourage more people to seek help, he said. “If we can treat more of these patients in a primary care setting, where they’re already getting care, or in other less stigmatized settings outside of substance abuse clinics, more patients will be able to get the treatment they need,” said Dr. Dimitri, vice-chair of family medicine and community health at University of Massachusetts Memorial Medical Center and UMass Medical School.

More Training for Doctors

Dennis Dimitri, M.D.
Dennis Dimitri, M.D.

Dr. Dimitri also believes it is incumbent upon all physicians to learn more about alternatives to opiates. “We need to familiarize ourselves with other modalities — treating underlying mood disorders, physical therapy, acupuncture, and other approaches,” he said. Dr. Dimitri, like others interviewed for this article, would also like to see physicians do a better job of teaching patients how to properly dispose of unused opioids.

The MMS must take more of a leadership role in educating physicians of various specialties about pain management and addiction, including developing curriculum, according to Barbara Herbert, M.D., director of addiction services at Steward Medical Group. “The Society needs to work on training people to not just treat pain, but also to help patients deal with the complex medical, spiritual, and physical disease which is addiction,” said Dr. Herbert.

She also believes that more physicians must learn how to intervene earlier in the addiction trajectory. “I compare this to asthma,” said Dr. Herbert. “People who have a bad asthma attack may need to go the ER, but they can avoid the ER if you can figure out they have asthmas earlier and prescribe an inhaler. That’s the end of the spectrum doctors have not taken on.”

Physician Monitoring Program Improvements Needed

Notwithstanding physicians’ important role in helping stem the tide of overdose deaths, how much of the problem can be traced back to problematic prescribing patterns and how much to other factors?

Barbara Herbert, M.D.
Barbara Herbert, M.D.

“We don’t know if doctors are giving out more pills, if there are too many unused pills in people’s medicine cabinets that are getting into the wrong hands, if joblessness is a major driver of what’s going on,” said Dr. Herbert. Some physicians like Dr. Dimitri questioned if some responsibility might lie higher on the supply chain, since the amount of opioids that are manufactured each year exceeds the legitimate medical demand, he says.

Although many physicians criticize the state department of public health’s online Prescription Monitoring Program for being clunky and lacking real-time data, once planned improvements are made, its data should be mined for insights into the source and solution to the opioid problem, says MMS Legislative and Regulatory Counsel Bill Ryder.

“If there’s a connection between prescribing and addiction, they should be able to find that in the data,” said Ryder.

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