In the JournalsPerspective

Office visits dedicated to chronic pain management lead to lower opioid use

Kevin McCann
Kevin S. McCann

More than a third of patients taking opioids who participated in mandatory office visits dedicated solely to nonmalignant pain management decided to stop using opioids, according to findings recently published in the Journal of the American Board of Family Medicine.

“We are not aware of anyone publishing results of a mandatory, structured approach to management of nonmalignant chronic pain with opioids that involved visits dedicated solely to management of this single issue,” Kevin S. McCann, MD, associate professor, family and community health, Marshall University Joan C. Edwards School of Medicine in Huntingdon West Virginia, told Healio Family Medicine.

Researchers asked 32 patients in a rural area to switch to a new care system. These patients then had to choose between transferring care, slowly stop taking the opioids or stay on opioids. Those who stayed on the opioids had an office visit focused on nonmalignant chronic pain management every 3 months. During these visits, physicians verified the controlled substance contract; assessed mood, functional status and pain; computed the average morphine equivalents taken; took patients’ pain-targeted history and physical; screened urine; and confirmed board of pharmacy monitoring.

McCann and colleagues found that 12 of the patients chose to slowly stop taking the opioids, 17 continued opioid medication, and three transferred care. The mean morphine equivalent mg per day was the most important prime determinant for ability to wean (17.01 mg/day) compared with maintaining (30.61 mg/day) (P =.0397; 95% CI, 0.68–26.51). Patients who chose to maintain opioid treatment had no signicant change in any measured criteria during the entire evaluation period.

“Showing that you can have 38% of patients choose themselves to stop opioid use is a good thing,” McCann said in the interview. “This can enable providers to engage in a process that they know has some impact on the major opioid problem. It can also reduce provider angst in regards to meeting regulatory requirements. It also can serve as a means to unburden primary care physicians who are dealing with multiple chronic health problems by allowing them to dedicate a visit solely to one issue. The combined elements of reducing burden, reducing angst and the feeling of making a difference in a major problem can potentially help reduce physician burnout.”

“This was a small study done in a single practice. It would be very interesting to see if these results could be reproduced on a larger scale and thus determine if they are generalizable,” he added. - by Janel Miller

Disclosure: The authors report no relevant financial disclosures.

 

Kevin McCann
Kevin S. McCann

More than a third of patients taking opioids who participated in mandatory office visits dedicated solely to nonmalignant pain management decided to stop using opioids, according to findings recently published in the Journal of the American Board of Family Medicine.

“We are not aware of anyone publishing results of a mandatory, structured approach to management of nonmalignant chronic pain with opioids that involved visits dedicated solely to management of this single issue,” Kevin S. McCann, MD, associate professor, family and community health, Marshall University Joan C. Edwards School of Medicine in Huntingdon West Virginia, told Healio Family Medicine.

Researchers asked 32 patients in a rural area to switch to a new care system. These patients then had to choose between transferring care, slowly stop taking the opioids or stay on opioids. Those who stayed on the opioids had an office visit focused on nonmalignant chronic pain management every 3 months. During these visits, physicians verified the controlled substance contract; assessed mood, functional status and pain; computed the average morphine equivalents taken; took patients’ pain-targeted history and physical; screened urine; and confirmed board of pharmacy monitoring.

McCann and colleagues found that 12 of the patients chose to slowly stop taking the opioids, 17 continued opioid medication, and three transferred care. The mean morphine equivalent mg per day was the most important prime determinant for ability to wean (17.01 mg/day) compared with maintaining (30.61 mg/day) (P =.0397; 95% CI, 0.68–26.51). Patients who chose to maintain opioid treatment had no signicant change in any measured criteria during the entire evaluation period.

“Showing that you can have 38% of patients choose themselves to stop opioid use is a good thing,” McCann said in the interview. “This can enable providers to engage in a process that they know has some impact on the major opioid problem. It can also reduce provider angst in regards to meeting regulatory requirements. It also can serve as a means to unburden primary care physicians who are dealing with multiple chronic health problems by allowing them to dedicate a visit solely to one issue. The combined elements of reducing burden, reducing angst and the feeling of making a difference in a major problem can potentially help reduce physician burnout.”

“This was a small study done in a single practice. It would be very interesting to see if these results could be reproduced on a larger scale and thus determine if they are generalizable,” he added. - by Janel Miller

Disclosure: The authors report no relevant financial disclosures.

 

    Perspective
    Lawrence Greenblatt

    Lawrence Greenblatt

    Medical care for individuals suffering chronic pain has undergone dramatic changes in the last 20 to 25 years. Primary care physicians were encouraged by manufacturers, clinical guidelines and professional societies to manage pain more aggressively using opioids. This and other factors have contributed to a fourfold increase in opioid prescribing with a concomitant increase in opioid overdose deaths, ED visits and opioid misuse.

    We are currently in an era where safe prescribing of opioids has become an expectation, and prominent guidelines such as the CDC’s Guideline for Prescribing Opioids For Chronic Pain are promoted as expectations for providers. There are 12 major principles found in this guideline and many clinicians have found it difficult to incorporate these measures into busy clinical practice.

    PCPs in internal medicine and family medicine feel overloaded our panels are often full; care for many conditions, including hypertension, diabetes, heart failure and others, has become much more complex; patient involvement in the numerous screening and preventive measures requires shared decision-making; documentation is much less efficient; and the length of our appointments remains largely unchanged. It is not surprising that many PCPs report symptoms of burnout and depression.

    The article by McCann and colleagues provides a detailed, retrospective summary of one PCP’s approach to meeting the standards set forth in current practice guidelines. All patients on chronic opioid therapy were identified and a care strategy that met the standards was implemented with these patients scheduled on the same day each quarter. After notification of the plan, nearly half of the patients chose not to participate. Three of 32 changed provider and another 12 opted to taper off therapy. In the end, 17 patients were managed using the new approach. The number of patients was too small to assess clinical or safety outcomes. The workload for collecting data from the patients from their various self-report measures and documenting appeared to fall to the family physician who created process. The physician did not address other medical issues during these visits.

    Given the growing shortage of PCPs, I would like to propose a different model which would provide a similar structured approach. 

    • Patients would complete screening questionnaires electronically through a patient portal or via a tablet with the data uploaded at the office. If these are not available, the patient would be expected to complete the tools on paper prior to the visit.
    • A member of the office staff would review these documents and enter them into the electronic medical record.
    • The same staff member could then obtain a structured history regarding side effects, goals of care set forth by the patient, key elements of the pain management agreement, safe storage, etc., and this could be documented in the record as well. The urine drug testing and pill counts would be conducted under protocol.
    • The prescriber’s delegate would review the prescription-drug monitoring program and print out a report.
    • The prescriber could then efficiently review this information and also provide the patient’s comprehensive medical care.

    Ideally, Medicare, Medicaid and commercial insurers would allow for supplemental billing (analogous to G-Codes), which would cover the cost of staff time for providing this medical care. Without such funding, I’m afraid that most primary care physicians would forgo meeting the current optimal standards of providing chronic opioid therapy.

    • Lawrence Greenblatt, MD, FACP
    • Professor of medicine and community and family medicine, Duke University School of Medicine

    Disclosures: Greenblatt reports no relevant financial disclosures.

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