Hello, and welcome to another episode of the TMF Quality Innovation Network’s podcast series on evidence-based pain management alternatives. I’m Dr. Clifford Moy, the behavioral health medical director at TMF Health Quality Institute, a leading non-profit health care consulting organization based in Austin, Texas.
I'm joined by Dr. Lindsay Botsford, who is the market medical director for Iora Health in Houston, a clinical associate professor of the Department of Clinical Science at the University of Houston College of Medicine. Today we are speaking about examples of short- and long-term opioid treatments, pain measurement and side effects of opioids.
I wonder if you could just give us a couple of case examples of patients that you've had, either the simple or the complex treatment, and how you might approach their use of both short and long-term opioid medications. And I guess maybe we should talk a little bit about what opioid medications are for our listeners who aren't familiar with the term.
Yeah, that's right. So opioid medications refer to a broad category of pain medications. In the lay literature -- I shouldn't say in the lay literature. In the lay world, they are sometimes called narcotics. So that's more a slang term than what we would use in a medical setting. But these include things like hydrocodone, Tylenol with codeine, often known as Tylenol Number 3, morphine, fentanyl and tramadol, to name a few.
Yeah. There are lots of them out there. So give us some examples, if you can, about how you would approach patients and what their course of treatment would be like.
Yeah. I think one example that would be helpful to talk about is the same patient but with different things going on because that's going to change my treatment plan as to what I want to do for them. So let's take a 67-year-old patient who comes into your office on Hydrocodone. This is sometimes known as Vicodin. They're taking 5 milligrams, combined with the Tylenol 325 twice a day. Some days, she'll take three, but most days, she's pretty good about taking two. She seems to be benefitting functionally. She's able to do the things she likes to do. She doesn't report having any side effects or problems with the medications. When we talk about her risk factors for having problems with it, she doesn't have any significant risk factors. She's doing regular exercise and goes -- uses her app for her mindfulness once a day, let's just say. So for someone like that, you know, who is doing well, doesn't have any signs of abuse, you know, you're getting good functional improvement, you might want to think about adding physical therapy or things like that to it if her exercise wasn't enough. And mostly, she's doing well. So this is one of those patients where you probably would periodically want to try coming off of the opioid to see if there is something else you could use. But maybe you don't mess with it. I think that's not our common patient. So more commonly is a patient who's maybe taking these medications but isn't getting any functional improvements. And that's kind of our word for are they able to do the things in their daily life that they need to do? So this can be things like going to the grocery store, playing with grandchildren, being able to cook their own meals without having pain. So when patients aren't doing that, and they're taking the pain medicine, not getting great pain relief, that's when we want to think about changing up our plan. So for patients like that, we would want to add some formal physical therapy, do some prescribed exercises, or if you don't want to call it exercise, activity. Talk about things like weight loss if it's needed and work with our behavioral health professionals about coping skills, activation and things like that. When patients in that situation just want to continue the opioid but not do any of the other stuff, that's when we probably will want to think about slowing or stopping a course of opioids because we know these patients don't do very well in the long run. The opioid by itself just doesn't work.
Well, in the quality improvement world, we talk a lot about measuring things. With patients like this or any of your patients, how often do you talk with them about how they're doing on their activities of daily living, their ADLs you spoke of previously? How helpful is that to look at their progress and for them to understand what their progress or nonprogress might be with any particular intervention?
Yeah, so that's a great point. It's helpful to think about a comprehensive pain assessment whenever we see patients. So this goes beyond just using a pain score, that 0 to 10 rating scale. One that's helpful to use is a PEG, or the pain, enjoyment and general activity scale. And that's a three-question scale that talks about, you know, activity, things like how is the pain affecting your function. And it helps you to track it over time. So that tends to be more helpful than a one-time assessment. And, you know, effective care means that we need to make sure our patients feel empowered and in control. So whenever they're doing things that are good, we affirm those behaviors as part of it. You know, we also want to think about evaluating for other things that could cause problems down the line. That's usually a one-time thing in the beginning when we think about using something like an opioid risk tool to -- prior to initiation of medications like opioids. So that helps us screen for substance abuse history, psychiatric disorders or polypharmacy that might influence a patient's response. There are things we can do to track things over time. So using a brief pain inventory, we want to look at their mental health. So tracking things like a patient health questionnaire or a PHQ-9. The frequencies kind of depend on the patient. So this could be every month. It could be every three months. It's going to depend on how controlled the patient is, if they're having any changes in dose or changes in pain.
Sure. Do you have guidelines or kind of rules for prescribing opioids to patients? And do you tell them that when you see them and then say, "Hey, you got an injury or this is the cause of your pain. We're going to do this for either long-term or a time-limited treatment."?
Yeah. So there's a bunch of helpful ways to communicate with patients when we do initiate opioids that emphasizes the time-limited course of treatment. So first of all, when we think about framing chronic pain, we talk with patients about our goal being we want to help you learn to live with your pain. We're not going to try to get rid of the pain. We can always hope for it, but our success measure is the idea of learning to live with the pain and still being able to do all the things you want to do. The other thing we like to talk about is the fact that we can try some of these things, but we need to constantly reevaluate and think about when other things need to get in the mix. To get an idea of where a patient is when we're starting, I think it's helpful to ask, "What do you know about opioids?" Some patients are very informed. They have either taken one in the past and hated the side effects, have heard the news with all the scare of the opioid epidemic. But some patients don't. And so we want to talk about the fact that people have a higher risk of death on opioids. That 20% of patients who take an opioid long-term may become addicted. And then some of the side effects we don't always think about like increased risks of pneumonia in older adults.
Sure. And osteoporosis. With all of those things, it's not really helpful to cite the guidelines or talk about how I'm worried about my license when I'm prescribing. There's so many other reasons we can use that really are more patient centered in terms of talking about why an opioid might not be the right choice.
Well, it reminds me of the saying that pain is inevitable, but suffering is optional. So --
That's right. -- we can find, really look at ways to decrease that suffering. But there may be discomfort that goes on long-term. That pain may be something that cannot be eliminated. The other side effect that I was thinking of was the big C. And by the big C, I mean constipation, which is a frequent side effect with these medications and certainly in our older patients is a really, really significant thing. And I just read a review article in the Journal of the American Medical Association about it, so the -- specifically about the opioid-induced constipation. So it's a really important thing to known and talk to patients about. The other thing, you know, talk about treating pain, but we also want to, like you said, avoid any potential side effects or consequences like you've discussed. So you mentioned addiction or dependence, as you talked about. Are your patients concerned about that? Or are they just sort of in the moment and saying, "I need something to get rid of this pain."?
You know, every patient is different. Some patients are becoming more and more concerned about addiction or side effects. And I think it's balanced between both of those things. As you point out, constipation is probably the number 1 thing that patients feel with it. You know, one in three patients who take an opioid do get constipation as a result. It's frustrating because it's not always dose-dependent, meaning it doesn't just happen if you're on a high dose. It can happen at low doses too. So thinking about using a safe laxative or stool softener when you're on some type of opioid is an important strategy to prevent that from happening. But there's lots of other side effects too that patients need to be aware of. In older adults, opioid medications hang around longer. So even when a patient is taking it properly, they're more prone to side effects. So some of these are problems with balance, increased risk of falls, other things like decreased hormone levels, such as testosterone or estradiol, which can lead to sexual symptoms. The risk of hyperalgesia, which is a fancy word for an increased perception of pain, can happen when patients are on these medications over time. For older adults in particular, we don't hear a lot about osteoporosis, but opioids can also contribute to bone thinning.
Wow. And that's especially dangerous when we have patients who have osteoporosis to begin with. So there are some estimates that people who are on 50 milligrams of hydrocodone a day, which does sound like a lot, but they have a 10% increased annual risk of fracture in older adults, which is dramatic. The other one is a worsening of sleep apnea. So if patients have central sleep apnea, even worse, if they take it with a benzodiazepine medication, that normal response of the nervous system gets decreased with age. And so it leads to that respiratory depression or problems with breathing when you have sleep apnea and opioids.
All right. Let's load that up with the potentials for confusion and sedation in an elderly patient who already has osteoporosis, gets confused, gets out of bed and falls. We have a much, much larger problem at that point.
That's right. The combination of all of those side effects can be dramatic for an older adult. And that doesn't get at addiction, which is what you asked earlier. So it's often not even presented to patients as one of those side effects or risks. But it is very real. It can be up to 20% of patients were even with normal use, it can become an issue. And I think that's the thing patients don't realize. I think the word 'addiction' has all sorts of negative connotations. And we assume that you can only get addicted if you're trying to abuse it. But a lot of times, it starts with normal use and is one of the things that can happen over time as your body becomes dependent on it.
Sure. And one of the trends today is to avoid -- in a way, to avoid addiction is to avoid exposure. Hence, our use of alternative treatments or the use of nonnarcotic medications. Maybe you can take a moment and talk about it. How do you talk to patients about switching from opioid medications to nonopioid medications such as nonsteroidal anti-inflammatory drugs, NSAIDS? And how that might occur? And how effective has that been for your patients who have had some severe pain and now need to move to something that's not as potentially harmful in the long run?
Yeah. So I think a good thing to understand to answer that question is that 50% of patients often want to taper their dose if they're able to get their pain controlled. So as a physician, we should not assume that any patient wants to continue on an opioid. They want their pain treated, whether that involves an opioid or not. So there's lots of things we can try. There's, unfortunately, no right answer for everyone. And I think it's helpful to share that this may take a bit of experimenting to figure out what works for you. So while that experimentation happens, it's definitely patient-centered to continue to offer medications while you work on other medication options for the patient, assuming you don't have concerns for diversion or substance use disorder. But it can take some time. And we never want to rapidly cut someone off of opioid medications. The problem took a long time in the making, and we don't want to stop it too slowly.
That's right. You don't want to precipitate an acute withdrawal.
That's right. That's right. So the response to some of these guidelines has been let's take everyone off of opioids. And we probably should try. But when we're doing it, the taper is a lot slower than we think it is. So somewhere between decreasing dose between 2 and 10% a month, which can be very slow in trying a patient off of an opioid. Whether they're taking it because of, you know, legitimate pain or otherwise, when you've been on an opioid for a long time, your body naturally develops tolerance. And that's different from addiction. So whenever you try to stop, your body is going to have what you talked about, withdrawal symptoms. And those can be not fun at all. There's ways you can work with your doctor to help prevent some of those symptoms along the way so that it makes it easier to make a switch. So when a patient tries to stop an opioid, they'll often get diarrhea, irritability, feel very anxious, have some nausea and vomiting. And we can manage that by using things like hydroxyzine for insomnia, cautioning our older adults to some extent. We can use things like anti-diarrheal medication to help the diarrhea that's going to come from it. Clonidine can help with some of the autonomic symptoms. So these are not medicines to treat the pain, but they help a patient who naturally is going to not feel good when they're trying to stop an opioid as we figure out what the right next step is.
Sure. We need to always be thinking about possibility of anti [inaudible] side effects --
That's right. -- especially in our older patients. You know, this brings up another aspect of where we are in today's environment, and that's that many physicians have elected to no longer prescribe opioid medications at all across many different specialties. And in that way, they've said, "If you need these medications, you have to go to a pain management specialist." And I'm just curious as to when do you refer patients to a pain management specialist? They're pretty hard to see these days because the demand is pretty high. And it also tends to fragment care.
That's right. To your first comment, although we should be careful about starting patients on opioids in the first place, there's lots of patients on them. And so the choice to just not prescribe is not want that's very patient-centered. We have to be careful as we deprescribe them, so we don't inadvertently cause harm to patients who need them and need the help coming off of them. Whenever we think about guidelines, they call for a patient-centered assessment, not a mandatory does reduction. So we need to think about being cautious about that strategy. So pain management, I think, is one tool in the toolbox in terms of who we can refer patients to. But I expand that more broadly to think about what other specialists we also refer to. And those involve our psychiatrists, our psychologists, our physical therapists, as well as our pain management colleagues in terms of referrals. In most cases, we're able to do a pretty good trial of things in a primary care setting. But our patients who should consider seeing a specialist are those who have pretty complicated histories, have had tried multiple times in the past the variety of strategies you would use in your toolbox, or pain that doesn't respond to your usual treatments. I think the other thing would be if you've done a good trial of conservative therapy, and you think it might be a patient where an interventional procedure could have a role, our pain management colleagues are wonderful. There's been numerous trials in the last few years showing that there's good evidence for a variety of procedures for chronic pain. So there's been looking at epidural steroid injections if there's acute radicular pain. There's spinal cord stimulation and intrathecal drug pumps for patients with persistent back and leg pain. They can do nerve denervation for some types of knee pains. So there's options out there. They tend to be more involved. And there is a price to them. So I think for most patients, we want to try some conservative treatment strategies first.
Sure. I'm thinking -- when you say denervation, I'm thinking about trigeminal neuralgia.
Yeah. And those are -- we're getting pretty far down the road to very much less common reasons for pain and for patients who have had a relatively long history of pain and documented entries for conditions over a long period of time. This is not someone who shows up in your office and in the first month needs something. They may need to -- if they're not responding to pain medications, they really may need to have that addiction evaluation to see where that goes.
Yeah. That's a good point. Our addiction medicine colleagues are an important resource as well because sometimes, that is the best solution. You know, instead of deprescribing or just choosing to not prescribe, one other strategy for our patients who we do recognize have an opioid use disorder is to consider treating them yourself in a primary care setting. So that does require getting your waiver, sometimes known as the DATA 2000 Waiver, to be able to prescribe medications for the treatment of opioid use disorder. And so instead of just responding by saying, "We're not going to prescribe opioids," primary care physicians can also get educated and get their waiver to be able to treat patients as well.
Yeah. I think that's medication assisted therapy or treatment, otherwise known as MAT, oftentimes uses -- makes use of Suboxone that's dispensed over a longer period of time. This is not methadone. Methadone is a completely different pathway as far as prescribing, dispensing and treatment goes. But those are our alternatives for patients who have long-term documented opioid dependence. It's not for everyone, and I certainly don't recommend that it be taken lightly.That's right. Yeah. Buprenorphine is the treatment of choice. You know, for the primary care setting, we can also use Naltrexone and Methadone, but those get a little bit stickier in terms of needing additional training to prescribe. But Buprenorphine has a long half-life, little abuse potential, a really good safety profile. And you can get a free waiver by doing 8-hour online training and applying for it.
But you're limited to a specific number of patients receiving that prescription.
There are limitations, and I think that is perceived as a barrier. For the first year, you can treat 30. And then it increases to 100. And then beyond from there, depending on comfort level. I would say unless you're running a pain management clinic, those first numbers are usually well enough to be able to care for the patients in your practice and provide a need in the service. You know, only 4% of family physicians even have a waiver. So a lot of these are done currently in the pain management world, but there is not enough people out there licensed to treat the number of patients that need it.
Okay. Dr. Botsford, thank you for your time today and all of your great knowledge.
All right. Thanks for the time.Bye bye.
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