Friday, October 23, 2009

Why Primary Care Providers Shun Opioid Therapy

Despite considerable research demonstrating that opioid analgesics can be valuable and effective therapy for many types of pain, and the recommendations of numerous guidelines, primary care providers often avoid prescribing these medications. Reasons for this run contrary to best medical practice.

Writing in Medscape Neurology & Neurosurgery, Bill H. McCarberg, MD — Assistant Clinical Professor, University of California San Diego School of Medicine; Founder, Chronic Pain Management Program, Kaiser Permanente, San Diego, CA; and a well-respected writer/lecturer — addresses the question of why primary care providers often do not adequately meet the needs of patients with pain by providing opioid therapy. He concedes that pain is undertreated, especially in the primary care setting. Primary care providers are usually the point of entry into the American healthcare system, and include family physicians, internists, osteopaths, pediatricians, gynecologists, and physician assistants and nurse practitioners. Even though more than 1 in 4 Americans report episodes of pain each year, 70% of persons with acute pain simply do not seek medical attention and hope that they can manage the pain on their own. Still, moderate to severe pain is one of the most common reasons for primary care visits in the United States; however, inadequate training among healthcare professionals may prevent proper assessment of pain conditions, and deficiencies in pain management related to patient gender, race, and socioeconomic status have been reported, McCarberg observes.

For either acute or persistent pain, opioids can be a valuable and effective option, he continues. “The contribution of opioids to improved function, sleep, mood, and pain has been demonstrated in multiple trials.” State medical boards have developed intractable pain acts to encourage all providers to manage pain more effectively and guidelines have been established for the use of controlled substances for the treatment of pain. Despite these advances, primary care providers are increasingly hesitant to prescribe opioids, largely due to concerns about patient compliance with treatment, the possibility of adverse effects or opioid abuse, and the perceived scrutiny of opioid-prescribing practitioners by regulatory authorities.

Additionally, both clinicians and patients are concerned that opioid therapy will lead to addiction, although only a small percentage of patients with pain actually develop iatrogenic (therapy-induced) addiction, according to McCarberg. Some of the confusion may stem from inconsistent use of the terminology or misunderstandings associated with opioid misuse, abuse, tolerance, dependence, and addiction. “The public health is not best served by decreasing the medical use of opioids even with increases in prescription opioid misuse and abuse,” he states. The potential for inappropriate medication use should be considered as part of an individualized risk-benefit analysis conducted for every patient being considered for opioid therapy. “Risk for aberrant drug use depends more on genetic and psychosocial factors, including personal and family history of drug abuse, the presence of psychiatric disorders, and a potential patient agenda for euphoria and abuse, rather than the mere exposure to an opioid.”

Commentary: Our bias is that opioid risk assessments, while appropriate in many but not all cases, should not incur a “cops ‘n robbers” atmosphere whereby all patients are viewed as potential opioid abusers until proven otherwise. McCarberg observes that, “The majority of patients who present to their primary care provider will be considered low risk and can be managed routinely [on opioids] in this setting.” In cases where a patient with pain has a known history of substance abuse or a complicating psychiatric disorder, consultation or referral to an appropriate specialist may be advisable, he recommends. However, this may not be practical for all patients and in all communities; the solution, we believe, is for healthcare providers to take the time and make the effort to become better educated on opioid prescribing and its possible complications, and to also better educate patients (and their caregivers) on potential risks and the safe use of opioid analgesics. The alternative — merely not prescribing opioids for pain conditions that could benefit from such therapy — is bad medicine.

Reference: McCarberg BH. Chronic pain in primary care. Medscape Neurology & Neurosurgery. 2009(Oct) [article available here].