On March 15, the Centers for Disease Control and Prevention (CDC) released guidelines intended to stem the tide of U.S. opioid addiction. The dozen recommendations represent a sort of 12-step program for primary care practitioners on the front lines of a battle killing more than 40 Americans a day. Step number one: Except for patients with active cancer or in palliative care, doctors should avoid prescribing opiate-based painkillers for patients with chronic pain.
The guidelines brought diverse reactions from primary care and addiction medicine experts at University of Colorado Hospital, ranging from “it’s a good start” to “too little, too late.” Steven Millette, executive director of UCH’s Center for Dependency, Addiction and Rehabilitation (CeDAR), said the fact that CDC took up the issue at all sends a message.
“The CDC gets involved when there’s an epidemic, so I think that says a lot,” Millette said.
Millette and others say that while the guidelines are non-binding, providers will have a hard time justifying not following them – if not because it’s a clearly stated, well-justified best practice, then in order to avoid potential exposure to litigation. He added that the hospital’s primary care clinics, with an assist from CeDAR, are already doing much of what the CDC’s guidelines recommend, and there’s more on tap.
Opioids – which include a long list of substances, starting with morphine and including hydrocodone, oxycodone, fentanyl, tramadol and a host of others – have proven to be as effective at ruining lives as they are at masking pain. The CDC guidelines themselves discuss the problem at length. In 2013, an estimated 1.9 million Americans were addicted to prescription opioid pain meds. From 1999 to 2014, 165,000 people in this country died of opioid medication-related overdoses.
Separately, the CDC reported that there’s been a 200 percent increase in the opioid death rate since 2000, and that 61 percent of the 28,647 U.S. overdose deaths in 2014 involved some type of opioid. That included heroin, which has had an upsurge in use, partly driven by people hooked on prescription painkillers.
When thousands of physicians prescribe millions of patients highly addictive painkillers for months or years on end, these things happen. It’s created a massive problem against which the CDC guidelines are “too little, too late.” as Patricia Pade, MD, put it.
“It should have been done a long time ago,” said Pade.
Pade directs CU’s Addiction Medicine Fellowship program (see related story in this issue) and leads a UCH clinic that aims to taper primary care patients at risk of opioid overdose off the drugs.
“The problem is now not so much about not starting people on opiates, but with all the people who were prescribed high-dose opiates,” Pade said.
The opioids have a two-decade head start. Pade well understands why all those opiates were prescribed for chronic pain (that is, pain that persists for more than three months, a point at which acute pain from injuries or surgery has usually abated). Painkillers live up to their name – at least in the short-term. But she adds that a growing body of evidence implicates opiates themselves in the perpetuation of pain. Some of that evidence comes from her team’s own work.
Kaylin Klie, MD, MA, the Addiction Medicine Fellowship program’s first graduate, is analyzing opiate dosing data from Pade’s patient pool. Klie will present her findings at the American Society of Addiction Medicine’s upcoming conference in Baltimore, Md. The results, Pade said, agree with those of a similar study Pade did in New Mexico: that prescribing fewer opiates in fact lessens the perception of pain among patients.
That’s counterintuitive, but there is ample evidence to support it, says Peter Smith, MD, a family medicine physician and assistant dean of Clinical Affairs at the University of Colorado School of Medicine. Our understanding of the transition from acute short-term pain to chronic pain is still developing, he said. But what seems apparent is that opioids’ relief of short-term pain “does something to the neurologic system that predisposes you to long-term pain, changing brain and spinal-cord chemistry in a long-lasting way,” Smith said. At the same time, he adds, long-term opioid use puts you at risk of overdose.
Smith feels that the CDC guidelines are a good start, and that they jibe with both CU’s and the Colorado Department of Regulatory Agencies (DORA) policy on prescription opioids. The latter was published in October 2014.
Supporting primary care
The hospital and University Physicians, Inc. have also teamed up to invest $150,000 in improving how UCH’s primary care clinics manage chronic pain, under the auspices of a Joint Primary Care Oversight Committee.
The effort has standardized guidelines relating to care for patients, including how to screen for them, how to manage them, and how to place them into appropriate categories in terms of overdose risk. It has also developed digital tools – a new Chronic Pain Resource Center website and the automation of such time-consuming but vital tasks as calculating daily morphine equivalents in the Epic electronic health record, a work in progress.
The website includes separate portals for patients, families, and providers. The patient portal describes the dangers of opioids for chronic pain, alternatives to these drugs (breathing exercises, stress management, relaxation tools and sleep tips among them), guidelines for preventing overdoses and other links. For providers, there’s a risk calculator; the CU Chronic Pain Management Guideline; assessment tools for chronic pain, anxiety, depression, substance use and other factors; policies and procedures for controlled substances; links for continuing medical education; Epic tools, and much more.
The work also involved hiring a practice coach, who helped the clinics implement the hospital’s opioid guidelines into their practices. The focus, Smith said, is on patient function.
“We want to help patients get their pain under control, but if we do that in isolation, there’s often a risk that their lives become worse if you take a holistic view of their life experience,” he said. With a broad approach to tackling pain, Smith added, patients “may have fuller and more functional lives, but the price of that is maybe not having their pain completely controlled.”
For front-line primary care providers, managing pain means a lot more than just prescribing pain pills. Chronic pain is, as Smith put it, “one of the most complex biopsychosocial problems encountered in medicine today.” At the same time, he said, “practices are under great pressure to see more patients in less time.”
The implications of providing more holistic care for chronic pain patients – not to mention those already addicted to painkillers – are profound, Smith says. How does the current push toward integrated behavioral health and primary care account for chronic pain (which often has both mental and physical health factors) and opioid addiction? Will payment reform embrace the intensive therapies required for a more nuanced approach to caring for those with chronic pain and addiction resulting from opioids’ role in treating chronic pain? Will the move away from opioids be joined by regulatory reform, such as changes to the HCAHPS patient-satisfaction reporting on how providers manage pain?
Pade, for her part, is focusing on using embedded clinics to improve care for chronic pain patients who are addicted or at risk of addiction. She leads one for the A.F. Williams Family Medicine Clinic (the clinic itself has moved to CeDAR because of demand and space constraints in Denver’s Stapleton neighborhood). She’s also running a consult service for UCH inpatients, she said.
Having someone besides the primary care provider tackle the problem can be good for doctors and patients alike, Pade said. Taking patients off pain meds they feel they need to function is fundamentally confrontational, “which is not what most primary care providers want,” she added.
Pade has hired another addiction medicine physician, Amir Eissa, MD, who will start in July. He and Pade will work with A.F. Williams and Anschutz Medical Campus patients as well as those in Boulder. They’ll be plenty busy, she said.
“We need about 500 or 1,000 more of us to handle this mess,” she said.