Two recent studies led by University of Colorado School of Medicine physician researchers have defined key problems related to opioid pain medications for patients with chronic pain. They represent early, important steps toward helping patients get off long-term opioids and hospital physicians make the right decisions about these difficult cases.
Prescription opioid pain medications have become a massive problem in this country. While they can offer unparalleled short-term pain relief, an estimated 1.9 million Americans were addicted to them in 2013 alone. From 1999 to 2014, 165,000 people died of opioid medication-related overdoses. Opioid prescribing has increased more than six-fold in the past decade in the United States, and 9 million Americans report long-term medical use of opioids despite a lack of evidence that they offer any long-term help at all.
Those last two points are from the lead-in to a study that CU School of Medicine Internal Medicine physician Joseph Frank, MD, MPH, and colleagues in May. Their aim was to understand what patients on opioid medications for chronic pain fear about tapering off them, how patients who were tapering or had tapered were faring, and what primary care physicians and others might be able do to help these patients leave the drugs behind.
The second study, led by Frank’s colleague Susan Calcaterra, MD, MPH, focused on hospitalists – doctors who treat hospital inpatients – and the challenges they face when confronted with patients who use opioid medications for chronic pain management.
Qualitative, not quantitative
These studies don’t read like your typical research reports. Rather than error bars, P values, hazard ratios and other statistical distillations of quantitative data at the heart of so much academic medical research, one finds frank descriptions of drug withdrawal. “I don’t think they’re aware of how bad withdrawals are,” reads one. “I mean there’s vomiting bile. There’s stomach cramps, there’s cold shakes and fever… I mean it’s pretty bad.”
Frank’s and Calcaterra’s studies are both qualitative. They focus on interviews with about two dozen patients with chronic pain (one of whom shared the quote above) and hospitalists, respectively. Rather than definitive answers, qualitative studies seek to frame the key questions that future quantitative research might answer in pursuit of better standards of care.
Qualitative research can be of great value in exploring the roots of widespread, complex problems, such as the prescription of opioids for chronic pain, which, as Frank put it, represents the “unusual intersection of an important and widespread challenge with the absence of evidence to guide patients and providers.”
Daniel Matlock, MD, MPH, a co-author of Frank’s study who treats both primary care and palliative care patients at University of Colorado Hospital, added that there’s little agreement among physicians regarding how to deal with patients with chronic pain who are taking powerful drugs over the long term.
“This is really a controversial topic among doctors right now,” he said. “It’s the wild West.”
Frank assembled a research team that included primary care physicians, hospitalists, addiction medicine specialists and others. They helped recruit a diverse group of hospital patients from UCH, the Denver VA and Denver Health and developed and honed interview questions. The team enrolled 24 patients with chronic pain who had been on opioid therapy for an average of nearly eight years. Twelve patients were in the process of tapering their medications (cutting back with the aim of leaving the pills behind entirely), six were still taking the meds, and six had found success with tapering and no longer took them.
Among the findings:
• Patients who took opioids weren’t worried about overdose. Said one patient, “Overdose? No. I’m very mature, very conscious, very intelligent as far as adhering.” They worried much more about managing their pain and withdrawal symptoms.
• They considered opioid side effects such as drowsiness or constipation a small price to pay for pain relief they perceived to gain from their opioids.
• Among those who had already tapered or were in the process of tapering, several described having few or no withdrawal symptoms.
• Several of those who had tapered found their pain levels not to have changed much. “After you’ve taken it for a while, it doesn’t do any good. That’s what I’ve found,” one said. The interviewees also reported improved quality of life.
• Having positive relationships with trusted health care providers as well as social support outside the health care system was a big help to those who had successful tapered.
For primary care physicians and health care systems, there are big implications, Frank said. If patients perceive little risk of opioid misuse or overdose, then focusing on it – which, for example, the CDC’s new guidelines on opioid prescriptions do – might not be an effective strategy with patients with chronic pain. Rather, he said, it may be better to emphasize two things: first, that opioids can lose their effectiveness over time, so cutting back may not affect pain or make it worse; and second, that there are ways doctors can help patients manage withdrawal symptoms.
The ultimate message, Frank said, is that “a change in dose is a means to an end that makes you feel better and live better as opposed to an end unto itself.”
For health care systems, the study participants’ consensus that “supportive, nonjudgmental, flexible, accessible” providers were central to opioid-tapering success hints at a need for doctors to spend more time helping patients through the process – not easy given how busy providers are already, Frank said. Participants also said they would gain from peer support or access to those who had already tapered, which hospitals and clinics could help organize, he adds.
Frank said the findings support chronic pain’s status as itself a chronic disease as opposed to a major symptom of another condition. As such, effective care might take cues from team-based approaches that are standard in chronic disease management of such things as diabetes and heart failure. These typically involve longer visits and better engagement using multiple tools implemented over time, Frank said.
“The tools exist and the concepts have been introduced elsewhere,” he said. “It’s just one more place that I think – at a particularly high-stakes time – they’re needed.”
In the hospital
Calcaterra’s study considered the chronic pain opioid issue through the lens of doctors who often find themselves in a tough spot. Her study involved interviews with 25 hospitalists working at UCH, the Denver VA and Denver Health as well as two South Carolina hospitals.
Hospitalists – Calcaterra is one of them – are in a tricky position. For one thing, they rarely see patients twice. That’s a big deal, she said.
“We don’t know the patient, we don’t know his pain tolerance, we often don’t know the patient’s history of substance use disorders or mental health issues,” she said. “So there are a lot of unknowns when trying to manage chronic pain.”
In addition, most hospitalists have been burned by patient deception. Doctors interviewed for the study recounted such stories as patients changing a prescription from 18 to 180 pills (unsuccessfully, in the end) and crushing an oxycodone pill and shooting it up through a central line (death by overdose).
“You take it very personally,” Calcaterra said. “If that happens on your watch, you feel that you are responsible, and I think that really impacts your practice going forward.”
Complicating matters are institutional pressures. Hospitalists must diagnose and treat quickly and efficiently, which generally rules out long sit-downs with chronic pain patients they’ve just met and will probably never see again. Also, managing pain is viewed as a pillar of successful health care, and patients’ opinions on how well doctors and hospitals ease their pain land in the publicly available Centers for Medicare and Medicaid Services HCAHPS survey of inpatients. The hospitalists Calcaterra and colleagues interviewed also described cases in which they prescribed chronic pain patients more opioids than they felt was ideal because if they didn’t, patients might end up back in the hospital with the same chronic pain.
Calcaterra said her study points to three ways to help address the challenges hospitalists face when deciding whether and how to prescribe opioids for chronic pain. The first is to involve a non-physician patient navigator who can take the time to understand the patient’s needs and goals as far as pain care and pass the information along to the hospitalist. The second is to develop guidelines for appropriate doses for opioid therapy at discharge. And the third is to improve communication among hospitalists and the primary care physicians who know the patients best.
More generally, Frank and Calcaterra say that the medical education system needs to improve physician understanding of opioid prescribing. It’s hard to stump a good doctor when it comes to problems like diabetes management or treating infections, Calcaterra said, “but pain is ubiquitous and we get very hodgepodge training.”
Christine Jones, MD, MS, a hospitalist at UCH, said Calcaterra’s findings resonate with her experience, adding that physician assistants and others who deal with pain control and medications at discharge are in similarly difficult positions. They don’t want patients to suffer, but they also don’t want the narcotics to harm them. Calcaterra’s study is “absolutely helpful,” Jones said.
“I think we’re in the exploratory phase in terms of being able to define the problems from the patient perspective and the provider perspective and understand how to make the system better,” she said.
Despite all the statistics related to opioid use and abuse, it’s important not to lose sight of the fact that the vast majority of patients with chronic pain seek opioid painkillers for a simple reason, Matlock said.
“These are human beings who don’t want to be sick,” he said. “And we don’t want to have patients in pain.”