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regarding the impact of the new legislation on primary care providers. Dr. Lagisetty’s research interest is prescribing practices and she has worked with others in this field both in Boston and in Michigan. She explained the extra burden that managing these patients will entail: it’s not training, it’s time and trouble.
■ In general, I don’t think (doing this) requires additional training. It just requires additional time, frequent appoint- ments and focused conversations about expectations, goals – about pain management. This is not including all of the regulatory hurdles of checking PDMP’s, urine screens, filling out prior authorizations, etc. This is hard for any doc, particularly a primary care doc who is being held to meet other quality metrics for the other comorbidities their patients have (e.g., diabetes, hypertension, etc).
■ It also requires patience and (a great deal of) empathy.
There is a difference between your body being dependent on a
medication for years versus being addicted. How you think about these distinctions really impacts how you interact with your patients.
■ It takes time and trial and error: We don’t expect our smokers to stop smoking the first time we say it to them, or the first time we prescribe a nicotine patch. It may take many attempts and trial and error with different medications/ non-pharmacologic treatments. I think in an ideal world doctors would have some other team member to help support this. A nurse case manager, or social worker, or pharmacist that could have focused meetings about patients’ pain and do frequent check-ins.
These types of services need to be better reimbursed. If they were reimbursed as well as pain related procedures (e.g. injections), I think more docs would be willing to take on these patients and build the support team needed to care for them to help get them off these medications.
There are 3 types of patients for whom opioids are prescribed: patients with acute pain, patients with chronic pain, and those with SUD. The legislation makes no distinction among the three, despite their being quite different problems, and thus has unintended conse- quences for patients with chronic pain.
Primary care providers are likely to be called upon to manage the first two types of patients: those already in their practices who have been on chronic opioids (or benzodiaz- epines) for many years, are dependent but not addicted or drug seeking; and new patients who are already on opioids. Patients with true substance use disorder are a minority, but they have gotten more attention.
Dr. Lagisetty made several cogent points. First, she doesn’t think most primary care physicians need special training to manage patients with chronic pain and try to wean them off unnecessary opioids. But this is hard to do. What these patients need from their primary care providers is in short supply: frequent appointments, conversations focused on their pain issues, lots of empathy and lots of time. The demands of the current system, lack of time, regulatory and documentation requirements make it difficult to do what is needed.
The current health care system is not very supportive. There is neither additional manpower (allied health professionals) nor better payment. (Pain procedures
pay more but are not the answer.)
She made an instructive analogy to weaning patients
from tobacco use. Yes, it is important to get patient to quit smoking, but it can take months or years of persis- tent effort working with these patients to be successful. Weaning patients off opioids often requires trial and error and takes a long time. The patient has to be willing to cooperate. You can’t just stop the prescribing, or switch to another drug; you have to work with the patient as an individual. (Most of these patients are not drug seeking; they do not need buprenorphine, which is really for patients with addiction and substance use disorders; but they may not see the need to come off the drugs they have been taking for a long time.) The lack of support leads to frustration, which leads to not accepting any new patients on chronic opioids and to avoidance of writing new prescriptions for patients with acute pain.
Referral to a “pain” clinic or doctor is not the answer. There are not enough of them and their focus may be more on profitable pain-relieving procedures than on counseling and prescription management.
What will patients do who cannot be weaned? In Boston, Dr. Lagisetty saw heroin use. In Michigan, she has seen more marijuana use.
The Bottom Line: Unintended Consequences
Despite the recommendations of commissions and task forces for the adoption of broader (and more expensive) measures to combat the “opioid crisis,” the regulatory and legislative response focuses almost exclusively on restricting and overseeing prescribing practices. And while, yes, there is good evidence that opioids are overprescribed for acute pain, and yes, there have been pill mills exacerbating the problem, the underlying causes are much broader. The emphasis on preventing opioid dependence is important, but it is not necessarily going to be the answer. Thanks to programs like Michigan OPEN, Surgeons are learning to reduce the amounts of opioids they prescribe after operations, and there is new attention devoted to take-back programs for unused drugs. Only time will tell what they are and if this legislative fix will reduce opioid misuse and abuse and opioid related deaths. But I think we can be sure that this narrow focus on one small aspect of a much larger problem will have unintended consequences for most physicians and for their patients.
Editor’s Note
Dr. Berland and Dr. Lagisetty recommended the article “The Conundrum of Opioid Tapering in Long-Term Opioid Therapy for Chronic Pain: A Commentary.” For them and this author, terms like “complex persistence dependence” and “persistence abstinence syndrome” aid in the discussion of buprenorphine as an effective pain treatment for patients and offer clinicians practical management principles. To access the discussion and the charts, click here: full/10.1080/08897077.2017.1381663.
12 Washtenaw County Medical Society BULLETIN APRIL / MAY / JUNE 2018

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