By Emily Bazar
Kaiser Health News
Those of you who have experienced pain, especially gnawing, chronic pain, know that it affects your happiness, outlook and ability to function.
In the past couple of years, the treatment of chronic pain has undergone an earthshaking transformation as opioid addiction continues to claim — and ruin — lives.
Many primary care doctors no longer liberally prescribe opioid painkillers such as oxycodone, fentanyl and hydrocodone for back pain, migraines and other chronic conditions.
Instead, they are increasingly turning to alternative medications and non-drug options such as acupuncture and physical therapy.
“Most primary care doctors are afraid to do pain management because of the opioid backlash,” says Michael McClelland, a health care attorney in Rocklin, Calif., and former chief of enforcement for the state Department of Managed Health Care. “Either they don’t prescribe anything, and the patient remains in pain, or they turn them over to pain management specialists so someone else is writing that prescription.”
As a result, McClelland says, “people in genuine pain are going to find it more difficult to get medicine they may well need.”
Anita A., who asked that her full name not be used to protect her family’s privacy, says that happened to her father, Fred, when they moved from Maryland to the Sacramento area in November.
Her father, 78, suffers from back pain that two surgeries did not alleviate. For more than a decade, he took opioid medications under the supervision of pain specialists in Maryland. He has tried “every other medicine,” in addition to acupuncture, nerve block injections and more, but the opioids worked best to control his pain, she says.
“He doesn’t take more than he needs and he’s not seeking to take more,” Anita says.
But in California, two pain specialists declined to see her father, saying his case was too complex. Finally, a primary care physician referred him to a different pain specialist, who saw him in January, three months after starting the quest.
“It’s frustrating,” Anita says. “You get the sense that they’re looking at everyone as a potential addict.”
A year ago, the Centers for Disease Control and Prevention issued new guidelines for primary care doctors prescribing painkillers for chronic pain, which did not apply to patients receiving active cancer, palliative or end-of-life care. The guidelines recommend doctors first prescribe non-opioid medications, such as ibuprofen and acetaminophen, and urge non-drug treatments such as physical therapy.
When opioids are used for acute pain, such as that caused by injury, the guidelines suggest doctors prescribe the lowest-effective dose for the shortest-possible time — often three days.
For instance, the state of Washington issued its own prescribing guidelines years before the CDC did, he said.
“There was pushback even before the CDC guidelines, but the CDC guidelines brought this out at a national level,” Stanos says. “Physicians and hospitals are a lot more careful about how they prescribe, and to whom.”
In California, a statewide database known as CURES records opioid prescriptions. Last year, Gov. Jerry Brown signed a bill that requires prescribers to check the database to see if their patients have received these drugs from other doctors.
Opioids are highly addictive, and over time patients need higher dosages to achieve the same pain relief because their bodies develop a tolerance to the drugs.
“We don’t have any evidence to support the use of daily opioid therapy beyond about three months for chronic, non-cancer pain,” says Dr. Ramana Naidu, an anesthesiologist and pain management specialist at the University of California, San Francisco. “All of these individuals who have been on opioids for years and years have been doing so without any support from medical literature and science.”
Long-term use also comes with a plethora of possible and unpleasant side effects: constipation, confusion, low testosterone, difficulty urinating, weakened bones and more. And in a counterintuitive twist, opioids can make patients more sensitive to pain.
In some specific circumstances and at a low dosage, opioids can be used over the long term for chronic conditions when “patients have improved quality of life and function, no side effects and no concerns about misuse, abuse or addiction,” Naidu says. But in those cases, he requires his patients to take a “vacation” from opioids every two to four months.
As the CDC guidelines recommend, pain specialists are now looking to non-opioid medications plus a variety of non-drug treatments to help patients with chronic pain. These include acupuncture, massage, yoga and visits to pain psychologists.
Penney Cowan, founder and CEO of the American Chronic Pain Association, based in Rocklin, worries that some doctors aren’t treating their patients as individuals with unique needs. She’s hearing from members whose primary care physicians are simply refusing to refill their opioid prescriptions.
“The doctors are afraid,” she says. “It’s not good that a lot of people are being cut off cold.”
Liz Helms, president and CEO of the California Chronic Care Coalition, believes some people in chronic pain should be able to get opioids, as long as their use is carefully managed by physicians. She had to rely on them in the past after jaw surgery and again after she snapped her back in November, she says.
“That doctor-patient relationship is key to ensuring that someone stays out of pain so they can function,” Helms says. “To take people off a pain medicine that allows them to work and live with a good quality of life is inexcusable.”
Clearly, there’s disagreement between some doctors and patients on this. If you end up stuck in the middle and in pain, I have a few suggestions:
First, you’ll probably need to accept that drugs, especially opioids, aren’t going to be the cornerstone of your pain management. Be open to other options, whether alternative medications or other therapies.
“It’s harder work. It’s not the quick fix opioids are. But in the long run, they are better for your health,” says Dr. C.Y. Angie Chen, an assistant clinical professor at Stanford Medical School who specializes in addiction medicine.
Second, be honest with your doctor and ask questions. If your doctor wants you to quit opioids, ask her to explain how she plans to taper you off.
And if you haven’t already seen a pain management specialist, request a referral. Cowan suggests talking with your pharmacist as well. “Pharmacists are the most accessible of all,” she says. “They can’t prescribe, but they can provide useful information about medications.”
Check out the “Pain Management Tools” section of the American Chronic Pain Association’s website for more resources, or call 800-533-3231. Ask about the support groups it sponsors.
The American Academy of Pain Medicine offers a list of organizations for people with pain at www.painmed.org/patientcenter/. Among the organizations is the U.S. Pain Foundation, which also provides links to dozens of other groups that may help.
Finally, Dr. Chrystina Jeter, clinical instructor of pain medicine at UCLA Health, wants you to know that she and other pain docs are on your side, even if you don’t agree with their decisions to change your treatment plan.
“If I tell you I have to taper your opioids or that I can no longer prescribe your opioids for you, it’s not because I want to make you hurt or that I don’t care,” she says. “My primary job is to keep you safe, and I have a lot of evidence now to suggest that the prescribing habits of 10 years ago were not in patients’ best interest in the long run.”