Cover: Reversing the opioid epidemic
What Colorado physicians need to know
by Lesley Brooks, MD
The opioid epidemic is one of the greatest challenges facing health care today and physicians have a role in reducing opioid misuse and abuse in our patients. Unfortunately physicians can feel like they are cast in an unfair spotlight with this issue. Tom Frieden, MD, MPH, former director of the U.S. Centers for Disease Control and Prevention, was correct when he said this is a doctor-driven epidemic. No one else prescribes these medications but physicians, dentists, veterinarians and other licensed health care professionals.
With that said, others contribute to this epidemic, including our partners in the pharmaceutical industry, hospital accreditation and other advocacy organizations. And perhaps most important, a lack of robust science about the effectiveness and consequences of chronic opioid medications – science that has evolved significantly since the early 1990s – has played a significant role. We now know that these medications can be and are addictive, no matter the patient population, and that these medications can be and are life threatening if taken inappropriately.
Policymakers and health care experts understand many of the challenges we face as physicians in our current health care environment. They know that it can be challenging to treat someone with multiple chronic medical conditions that can cause discomfort; that it can be challenging to distinguish between the person with opioid use disorder and the person whose pain may not be well controlled; and that it can be challenging to know when the person who has been taking their legally-obtained opioids safely for months has transitioned to misusing them.
Through my practice at Sunrise Community Health, which serves both Larimer and Weld counties, my team of providers delivers full-scope family medicine, including Medication-Assisted Treatment (MAT) for opioid dependence. The latter, including treatment for pregnant women, is conducted through a strong partnership with North Range Behavioral Health and SummitStone Health Partners. The real-world knowledge gained through our experience inside this collaborative model can be instructive for practices throughout our region to protect our patients and increase our quality of care for those suffering from chronic pain or opioid addiction.
Starting with the basics on opioids, it is important for physicians to understand that our patients do have legitimate and organic chronic pain conditions. They can and do develop opioid use disorder on the medications that we give them, even those who have a well-documented source for their discomfort and even those who have a history of using their medications safely. Sometimes patients present with descriptions of chronic pain that are difficult to attribute to a physical source, and that can sometimes be associated with psychiatric or behavioral disorders. It is critical to complete a good assessment to determine the appropriate treatment modality. Some types of pain are not likely to improve and may worsen with chronic opioid therapy, such as abdominal pain, headaches and neurologic pain.
Physicians have made some progress in addressing this epidemic. The latest figures from the American Medical Association show that the total number of retail-filled prescriptions for all opioid analgesics in Colorado decreased 13.3 percent between 2013 and 2016, from 3.7 million in 2013 to 3.2 million in 2016. And use of the Prescription Drug Monitoring Program (PDMP) in Colorado nearly tripled from 680,000 searches in 2014 to 1.5 million in 2016.
However, there is still a huge educational gap for making better prescribing decisions. Safe opioid prescribing is about understanding how to assess the person with chronic pain, including past medical history, past treatments for pain, what worked best to improve their function and what didn’t, imaging, other chronic conditions – both physical and mental, physical examination findings, and more. Safe opioid prescribing is also about making as specific a diagnosis as you are able based on the data you obtain, understanding what medications are available for the condition you feel you are treating and are appropriate for different types of pain, and then helping your patient select the safest regimen for their specific circumstances.
This may mean that opioids are not an option or that the opioids they request and the Valium they are already taking are incompatible and you cannot support that regimen. I urge all physicians to obtain the training needed to help strengthen your communication skills. In addition, I strongly encourage you to obtain a DATA 2000 waiver that allows you to prescribe buprenorphine (ex. suboxone) to treat opioid use disorder if and/or when it begins. It can also be helpful for some chronic pain indications.
It is important to establish the parameters within which you will prescribe opioid medications to your patients and the circumstances under which you will no longer be able to prescribe them. We refer to this as a medication agreement. In the past, it has been referred to as a pain contract. I prefer the term “agreement” because it implies a mutual understanding. Again I emphasize communication skills because I don’t like the idea that there are terms under which my patient will violate their contract and thus be discharged from my practice. Sunrise doesn’t use that language with our patients. We prefer the idea that there are parameters within which we will continue with the regimen that we have agreed upon and outside of which the terms of our agreement must change.
For example, if a patient is going to use methamphetamine while taking the oxycodone that I have prescribed, I am going to insist that he or she see our behavioral health therapist for substance use assessment and attend our weekly group visits (see next page) while working to stop the methamphetamine. If not, we must treat the chronic pain with something other than an opioid. Our therapeutic patient-provider relationship is never at risk because of misuse. If anything, it is an opportunity to enhance it, to understand better the conditions with which our patients struggle.
I encourage providers to understand the policies of their local emergency departments and how they will handle patient requests for pain medicines. It’s also a good idea to let them know how your practice is handling opioid prescribing and how they can refer patients back to your practice.
It is important to seek out training so that we can recognize opioid use disorder in the outpatient setting. (See DSM-V-Substance Use Disorder Diagnosis.) I emphasize this because the presentation often differs from what one might find in a traditional substance use treatment setting. Unless we are working in the substance use field, physicians are likely unaccustomed to addressing this issue in our offices.
With someone who is using heroin or other illicit substances, that conversation is clear, though not easy. But for someone who is obtaining the means of their addiction legally from you for what you and they believe to be a legitimate condition, the conversation that a physician needs to have when their use has become problematic is nuanced and often calls upon new skills from us. We need to understand the criteria for opioid use disorder and how to apply it.
Finally, I cannot emphasize enough the importance of checking the Colorado Prescription Drug Monitoring Program (PDMP). Registration as a user of the PDMP is mandatory in Colorado, though use of this critical tool is not currently mandated. This is one very important way to understand if, where and what type of controlled substances your patients may be receiving outside of your practice. It is an important, objective tool to use in initiating conversation with our patients around their use of opioids and other controlled substances.
The Colorado Consortium for Prescription Drug Abuse Prevention is a tremendous repository for state-specific information on this epidemic. They currently have a link to a two-hour physician CME course, “The Opioid Crisis: Guidelines and Tools for Chronic Pain Management,” in the resources tab of the top-bar navigation on their website, corxconsortium.org.
The North Colorado Health Alliance and the consortium have collaborated on the Colorado Opioid Epidemic Symposium, a series of provider education events offering CME and COPIC points. The symposium offers full-day, half-day and evening events for providers to obtain the skills highlighted in this article. The most recent evolution of the symposium is “Moving From What to How: Safe Opioid Prescribing for Chronic Pain,” a 3.0-hour evening CME program focused on educating providers and other members of the multi-disciplinary team. Providers and practices can request training by contacting Whit Oyler at email@example.com or Deirdre Pearson at firstname.lastname@example.org.
Lesley Brooks, MD, serves as the chief medical officer for Sunrise Community Health, is the assistant medical director for the North Colorado Health Alliance, and co-chair of the Provider Education Work Group for the Colorado Consortium for Prescription Drug Abuse Prevention.
Posted in: Colorado Medicine | Cover Story | Initiatives | Prescription Drug Abuse