The difficult choices: Managing chronic pain while avoiding opioid abuse

The first step, says Christopher J. Burnett, MD, an assistant professor of anesthesiology at the Texas A&M College of Medicine and director of the Baylor Scott & White Health's Temple Pain Clinic, is to follow the guidelines the United States Centers for Disease Control and Prevention (CDC) released last year. "The CDC guidelines, which outline when to prescribe these drugs and provide guidance for how to do so safely, are a good starting point for providers caring for chronic pain patients," Burnett said.

Despite the concerns of some patients, the CDC guidelines are not intended to apply to palliative care, hospice or to oncology patients being actively treated for their disease. "If they are providing end-of-life care, providers should do what is necessary to make the patient comfortable," Burnett said. "The CDC guidelines are intended for the typical chronic pain patient."

Sometimes the best thing to do for these patients is nothing. "Much of the time, the right thing to do for lower back pain is to simply wait," Burnett said. "It might be an acute injury that will heal on its own given a little time." If not, there are a number of other treatment options available including anti-inflammatory medications, physical therapy, transcutaneous electrical nerve stimulation (TENS) units, acupuncture and massage. If the patient does not improve over the course of three months with these conservative approaches, there are also a number of procedures that interventional pain physicians can perform to improve pain, enhance functionality and improve quality of life -- as well as avoid long-term opioid use.

"The population of patients who need opioids chronically is actually pretty small," Burnett said. "For most people, the prescription comes with an exit plan. These medications are now considered to be a way to bridge to the next line of therapy," which might be injections or a physical therapy regimen, or possibly further diagnostics like imaging or a surgical consult. "All of these are intended to reduce reliance on opioids," he added.

That reliance is well-entrenched into the medical system. "In the past, providers have been all too willing to give copious amounts of narcotics and continue to escalate doses based on reported symptoms without having a clear idea of why they're doing it or what duration," Burnett said. "In my training, I have been told that if someone isn't responding to their opioid treatment, you just need to give more, and that was kind of the accepted wisdom for a number of years -- that you're just not giving enough."

That kind of thinking is finally beginning to change. Not all types of pain respond well to opioid therapy, and opioids carry significant risk.

Anyone who is getting more than a few weeks' supply of opioids at Burnett's clinic is required to sign a comprehensive pain contract. Among other provisions, this document spells out that the patient will get their drugs from only one provider and one pharmacy and that they will take them exactly as prescribed. During treatment, the patient may be asked to undergo a drug screen, which looks for illicit drugs but also the prescribed opioid and its metabolites, or the substances left behind after the drug has worked its way through the body. "I need to verify that you're actually taking what I'm giving you," Burnett said.

The risky situations arise most often when the patient is also taking something else -- something the person prescribing the opioids doesn't know about. Mixtures of medications -- like opioids with a benzodiazepine for anxiety, or even simply cough syrup -- are typically what cause overdose deaths.

Still, it can be difficult to manage patient satisfaction -- an important part of the way physicians are evaluated these days -- with the mandate to limit long-term use of opioids. "We're expected to try to treat the patients' pain, but the only thing that is going to make someone seeking opioids happy is to feed their addiction," Burnett said. "I have to put the patient's life ahead of the patient's satisfaction, but sometimes that can lead to low satisfaction scores."

To manage expectations, Burnett begins any consideration of an opioid prescription with a frank discussion with the patient about the risks of opioids. They need to know that they will need to keep the drugs somewhere safe, preferably in a lock box that only they have access to because the risks of these medications are not just to the patients themselves. "They have to think about who else might be able to gain access to the pills; too many teens have become addicted from stealing opioids from a family member's prescription," he said. "It's a real responsibility to even have narcotics in the home, even when they are necessary."