A couple of years ago, I inherited a patient who was on both a patch for the powerful painkiller fentanyl and a high dose of oxycodone four times daily — and she didn't have cancer.
I had 15 minutes with that patient to get her medical history, review her medications, assess her current complaints, and decide whether or not to continue her opioid prescriptions. I had no paper records and a very poor electronic medical record system. I lacked a lot of the information I needed in order to prescribe such a high opioid dose.
However, if I refused to continue the opioid prescriptions, I would force the patient into withdrawal. I weighed my options and came up with a reasonable plan, but it would have gone much better if I'd had some guidelines to fall back on. Amid the hubbub of the community health center where I work as a nurse practitioner, I felt stuck and alone.
We primary care practitioners want to do what’s best for our patients, including those with chronic pain, who are often some of the most challenging patients to manage. We do not want to overprescribe a potentially addictive and lethal opioid medication. In the primary care setting, all of this decision-making is happening at once and the patient is waiting for your decision.
At the time I saw that patient on fentanyl and oxycodone, there were no formal guidelines to help me. Every provider on my team practiced differently. Some were quite liberal with their prescriptions; others rarely prescribed controlled substances. It seemed like everyone was making a personal judgment call and no one knew where to turn for proper standards of care.
These clinical decisions are not so clear-cut. For a practitioner, it is emotionally draining and time-consuming to halt opioids for a patient who has been prescribed them for years. Working in a community health center in Lynn, which, like many small New England cities, is ravaged by the opioid crisis, I have not met a single primary care provider who has decided to start opioids for a patient.
Rather, we are dealing with the “inherited” pain patient, who has been prescribed opioids by someone else. These patients usually end up with us because their previous provider left the practice, their insurance changed and they cannot see their old provider, or they burned their bridges and are looking for a new prescriber.
It’s hard to write guidelines for the management of chronic opioid therapy. The Centers for Disease Control finally came out with their first attempt in March of this year. Before that, there were a few government agencies that attempted to write guidelines on the topic, but they were weak at best, and certainly not widely followed.
Our health center decided not to wait, and has been working on our own set of guidelines for the past year. We saw the need and we stepped in to improve our care. We created a task force that includes primary care providers, RNs, behavioral health clinicians, and an addiction specialist. We looked at existing guidelines, literature on chronic opioids and chronic pain, and expert recommendations.
The CDC guidelines are excellent, but ours go further in focusing on behavioral health and addiction treatment: We require a urine drug screen at each monthly visit. We have fully integrated behavioral health into primary care, sharing the space. Every chronic opioid patient has to get a comprehensive pain evaluation — also a step beyond the CDC. And we have our own suboxone clinic — suboxone treats opioid dependence — though we're working to provide suboxone in primary care rather than making patients go to a separate clinic.
We are now in the process of spreading our knowledge and putting our guidelines into practice throughout the health center. So far, we have decreased the overall number of patients on risky opioid medications. More specifically, we have greatly reduced the number of those on the highest-risk medication combination: opioids and benzodiazepines. We have also increased our referrals to addiction treatment and improved our access to behavioral health treatment.
If that same patient on the fentanyl patch and opioid pills came to me today, I would be much better prepared. Perhaps more importantly, I would feel more confident and empowered. I now have standards of care and a health-center-wide task force to rely on. I would feel more supported in my decision-making. Patients need to know that they are in good hands. Our work has helped make this possible.
It has certainly been difficult. Providers are initially defensive when it comes to their prescribing practices. This is to be expected. But we need to start looking at chronic pain and opioid prescribing as we do other disease processes.
We have studies that tell us that chronic opioid therapy is not effective in improving function (and sometimes even pain) over time. We have studies that tell us that chronic opioids can cause low testosterone levels in males, chronic constipation, and even an increased pain response, among other side effects.
We have experts that tell us to prescribe only low doses of opioids and never to prescribe opioids and benzodiazepines together. We need to listen to these experts. The surgeon general recently sent individual letters to providers pleading with them to reduce their opioid prescribing.
It seems that we are always slow to adopt new guidelines. We are skeptical and resistant to change. This is one of those times when we need to speed up our acceptance. Talking about overprescribing is not enough. Primary care providers are good at following new diabetes guidelines. It’s time we do the same for chronic opioids.
Kathryn Takayoshi is a primary care nurse practitioner in Lynn, Mass., who works "on the front lines of the opioid epidemic."