I came across an interesting discussion about the best approach for a primary care physician to take when faced with the need to taper a pain patient off opioids. The expert cautioned against moving too aggressively.
“You have to convince them that continuing to take an opioid may not be in their best interest,” he writes. “That’s a big difference cognitively about how you approach this as a provider.”
As opposed to simply continuing to provide the opioids, or worse yet, cutting off the supply without the patient’s cooperation.
His idea: Introduce the subject during a regular office visit. Bring up the question of opioids, and whether the patient is still benefitting from that level of medication. Then work from there towards the desired change.
It’s a valid issue because newer research has suggested that chronic pain patients are not receiving much benefit (if any) from continuing opioid use — at least in terms of pain management. Their use of opioids is more likely indicative of dependence.
As for abruptly cutting the patient off, don’t. It creates an incentive to turn to illicit sources — something that since the advent of fentanyl is more dangerous than ever.
We all know that real recovery begins when patients themselves decide on a change of course. That usually occurs in predictable stages, from precontemplation (not yet acknowledging a problem despite evidence) to action (the patient is motivated to change, and actively taking steps towards that end).
That may not happen quickly. Chronic Pain Syndrome (CPS) is a complex mix of physiological and psychological forces, and requires formal treatment.
I’m not sure how much work can be done to motivate the CPS patient in the context of an 11-15 minute primary care visit – especially now, when office calendars are jammed. Research does indicate that the physician’s opinion carries considerable weight with most patients. But without additional follow-up, it’s hard to see how real change can occur.
To some chronic pain patients I’ve encountered, access to opioids had become almost a matter of life and death. Given the patient’s exaggerated emphasis on pain, simply bringing up the possibility of ‘doing without’ could be immensely threatening.
So I do think there is a role for special treatment tracks specifically designed for CPS patients with severe opioid disorders. I’m thinking of it as an intensive outpatient component, medically supervised, staffed by therapists and counselors, offering an array of alternative treatments that the patient can try out in a controlled setting. The program would of course work cooperatively with the primary physician and other providers to coordinate care.
Would there be enough demand to support such a program? If there isn’t now, I suspect there will be in the near future.
