By Annette M. Boyle
MINNEAPOLIS — For primary care providers in the VA healthcare system, the use of opioid therapy to alleviate chronic pain requires an ongoing balance of risks and benefits for each patient, a challenge made more difficult by the sheer number of veterans seeking treatment.
Careful initial assessment, an opioid agreement with patients and regular follow-up can reduce the risks while providing relief to patients for whom the therapy is indicated and effective, experts told U.S. Medicine.
|Erin E. Krebs, MD, MPH, core investigator at the Minneapolis VA Center for Chronic Disease Outcomes Research|
More than 50% of male patients in the VA report chronic pain; among women veterans, the prevalence may be substantially higher, as much as 75%.1
It also is likely to increase in the foreseeable future.
Chronic pain accounts for almost 1 in 5 ambulatory visits by current servicemembers and is the most frequently reported symptom in primary care settings, according to the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain.2
More than half of all non-cancer pain is managed by primary care physicians nationwide.3
While opioid therapy might help many of these patients, primary care providers must weigh the risk of drug dependence and abuse before writing a prescription. In 2010, more than 43,000 VA patients were diagnosed with opioid dependence.4 Nationwide, deaths from accidental overdose increased 124% between 1999 and 2007.5
“Opioid therapy is most challenging for patients with chronic neuropathic pain not associated with terminal illness,” Erin E. Krebs, MD, MPH, core investigator at the Minneapolis VA Center for Chronic Disease Outcomes Research, told U.S. Medicine.
“Its use in this population arose as a well-meaning extension of opioid therapy in cancer patients. Evidence for use of opioids for chronic pain is limited. We’re essentially conducting an individualized experiment for each patient,” she added. “Many patients will not benefit; some may be harmed, and it can be difficult to tell who might have trouble with opioid therapy.”
In an initial evaluation of patients with chronic pain, providers should assess whether opioid therapy is appropriate and what emotional and physical factors could be contributing to the pain. According to Krebs, patients with active mental health problems, such as severe anxiety, depression and substance abuse present complex management issues and generally should be referred to pain specialists or treated with an alternative therapy.
Patients on benzodiazepines and sedating drugs used to alleviate anxiety or reduce sleep disturbance have a markedly increased risk of overdose and death with high dose opioid prescriptions (greater than 100 mg of morphine equivalent) and should be very carefully evaluated and monitored, she added.
Comorbidity Increases Risk
“Many patients with comorbid mental health disorders are at higher risk for an opiate-related adverse event and will not be safe on opiates,” according to Ilene R. Robeck, MD, of the Bay Pines, FL, VA Healthcare System. “It is important for all providers who treat patients with chronic pain to know that there are many alternatives to opiates that may be more effective over the long run, even if they make take more time to initiate and monitor.”
“Opioids may be too risky to warrant use in a number of circumstances,” added Robeck, who is co-chair of the National VA Primary Care Pain Task Force. “These include comorbid medical problems made worse by opioids, such as respiratory or neurologic problems, comorbid mental health problems — which opioids worsen — such as depression or substance use disorder or lack of improvement on opioids at acceptable doses.”
Determining which patients are at high risk for adverse opioid events can be challenging. “There have been a number of interesting studies that show physicians tend to be overconfident in their assessments of who has a substance abuse problem,” said Krebs. “My advice: There are no great clues; universally monitoring patients is the safest way to go.”
Robeck encourages physicians to review and have patients sign an opioid agreement at the time of the first prescription, as a means of educating them about the nature of opioids and their risks in both short-term and long-term use.
“The idea behind an opioid agreement is to consistently outline the risks and benefits of therapy and establish the responsibilities of the physician and patient to ensure safe use. I have a standard conversation with patients that discusses what we’re hoping to see from the medications, such as improvement in function in day-to-day life and return to normal activities. It makes clear that, if we don’t see those improvements, we will not continue the medication,” Krebs said.
Robeck recommends including a discussion of the importance of non-pharmacologic therapy and lifestyle changes along with the opioid agreement. She said has been able to — by discussing the role of endorphins, dopamine, serotonin and norepinephrine in relieving pain — increase patient interest in activities such as exercise, intellectual stimulation and other appropriate recreation.
In addition to physical therapy and cognitive-behavioral therapy, Krebs noted that she sometimes focuses on ergonomic issues, particularly for patients such as truck drivers and those who work in front of computers and who sit for extended periods of time and suffer chronic back pain.Expert Advice to Help VA Primary Care Providers Reduce Opioid Prescribing Risks
Frequent follow-up required
Once an agreement is in place, providers need to see patients on opioid therapy regularly, to evaluate the treatment’s effectiveness and monitor drug use with urine screens, both Krebs and Robeck emphasized.
“Do not treat patients with opioids if you are unable to follow them adequately. If your practice is unable to see patients at high-risk weekly or monthly, then these patients should be treated with a non-opioid approach in primary care, with possible opioid therapy left to the specialists,” according to Robeck.
For lower-risk patients, follow up between one and six months might be sufficient, depending on the patient, Krebs suggested.
Urine screens may detect non-prescribed drugs or indicate that opioids are not actually being used by the patient, raising the possibility that the medications are being diverted. A suspicious screen result should be confirmed with a more sensitive follow-up test and the results discussed with the patient and/or caregiver, when appropriate.
A negative urine screen also can indicate that the patient is doubling up on medication earlier in the month, perhaps because of insufficient relief. If an addiction problem is suspected, referral to a substance abuse program and rapid tapering of opioids is recommended.
“Patients must elect to enter a substance abuse program; some never do. I stick with them to help manage the pain but taper the opioids as rapidly as possible,” said Krebs. “In some settings, physicians use an algorithm to calculate the taper; within the VA, pharmacists are very helpful with this. The key is to not stop so abruptly that someone goes into withdrawal.”
In cases where Krebs suspects diversion, she does not continue prescribing.
“Sometimes it seems ridiculous to do a urine test, but twice in my career I’ve found consistently negative results in older patients who were, clearly, not intentionally diverting their medications,” she recounted. “In both cases, we found younger family members were taking the medications themselves. In one instance, the patient was moved to another family member’s home and it became clear exactly what the problem was.”
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1. .Haskell SG, Heapy A, Reid MC, Papas RK, Kerns RD. The Prevalence and Age-Related Characteristics of Pain in a Sample of Women Veterans Receiving Primary Care. J Women’s Health. 2006;15(7):862-869.
2. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, May 2010. http://www.va.gov/PAINMANAGEMENT/docs/CPG_opioidtherapy_summary.pdf
3. Breuer, B, Cruciani, R, Portenoy, RK. Pain Management by Primary Care Physicians, Pain Physicians, Chiropractors, and Acupuncturists: A National Survey. Southern Medical Journal. 2010; 103(8):738-747
4. Improving Access to Opioid Agonist Therapy, QUERI Update, June 2012, http://www.queri.research.va.gov/about/impact_updates/SUD-oat.pdf
5. Bohnert AS, Velenstein M, Bair MJ, Ganoczy D, McCarthy JF, et al. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths, JAMA, 2011;305(13):1315-1321.