Guest Dr Dan Alford, professor of Medicine and associate dean of Continuing Medical Education at Boston University Chobanian and Avedisian School of Medicine joins host Dr Jill Jin, AMA senior physician advisor, to discuss the essentials of good pain care and shares strategies for mitigating risk and applying a team-based care and a patient-centered approach when treating acute and chronic pain.
Explore the Essentials of Good Pain Care toolkit here: https://bit.ly/3rng59H
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Speaker: Hello, and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today, solutions that help put the joy back into medicine. AMA STEPS Forward program is open access and free to all at stepsforward.org.
Jill Jin, MD, MPH: Hello everyone and welcome. This is Dr Jill Jin, senior physician advisor at the AMA and your host for today. Today on the podcast, we are joined by a special guest, Dr Dan Alford, who is going to discuss the essentials of good pain care and how to safely manage acute and chronic pain as a health care team, covering non-pharmacologic options as well as both opioid and non-opioid medications. We have a STEPS Forward toolkit on this topic available at stepsforward.org. And Dr Alford was a co-author on this toolkit. Just a quick note, as always, the focus of our podcast is practice improvement in innovation in terms of workflows and processes, and less so about clinical guidelines or best practices for clinical care. However, for this particular topic, by nature of the topic, we will cover both workflows as well as a little bit of clinical guidance. And now I want to introduce our guest, Dr Alford, who is a professor of medicine and associate Dean of Continuing Medical Education at Boston University, Chobanian and Avedisian School of Medicine.
He is on staff in the section of General Internal Medicine and Director of the Clinical Addiction Research and Education Unit at Boston Medical Center. He is the course director of the Boston University, Safer and More Competent Opioid Prescribing Education (SCOPE of Pain) program, which has successfully trained over 280,000 clinicians across the country. Dr Alford is also past president of the Association for Multidisciplinary Education and Research in Substance Use and Addiction. He has been recognized as a champion of change by the White House and has received the AMA's award for Health Education as well as the American Society of Addiction Medicine Educator of the Year Award. His clinical educational and research interests focus on safer and more competent opioid prescribing for managing pain and managing opioid use disorders. Dr Alford, thank you so much for being with us today. It is such an honor.
Dan Alford, MD, MPH: Well, thanks for inviting me. Happy to be here.
Dr Jin: So let's dive right in. The title of the toolkit that you co-authored for STEPS Forward is Essentials of Good Pain Care. Before we get into what those essentials are, can you first discuss the magnitude of the problem? So in other words, why is good pain care so essential?
Dr Alford: Yeah, I think part of it is it's one of the most common things that we see no matter where we're practicing, whether it's in the emergency room or whether it's in primary care or inpatient, we see a lot of pain. I don't have the numbers for acute pain, but I know for chronic pain, about 21% of our population when asked say they've had pain on most days, that's about 50 million adults in this country. So it's really common and we should know how to treat it. Unfortunately, many of us like I, we're not trained well in medical school or other health professional training on how to assess and manage and treat it over time. And so we've got a lot of work to do in terms of educating ourselves, but it's common. We should be better at treating our patients. It's actually the humane thing to do. I mean, people who have pain are oftentimes suffering and are disabled, and we need to try to help. I mean, that's why we went into training in the first place. So that's why it's important.
Dr Jin: Right. And we should not shy away from the problem.
Dr Alford: Yeah, I do think at this point it is worth distinguishing acute from chronic pain, and although it seems pretty straightforward and pretty simple, oh, acute pain is for a short period of time and chronic pain is long. It really is quite different both in the terms of the way that we should think about it and the way we should approach it. I mean, acute pain is a life sustaining symptom, right? It's adaptive and it elicits motivation to prevent further injury and allows us to heal. But chronic pain really is kind of a disease in and of itself. It's a maladaptive process and we know that it can be so severe and so long-term for some individuals that there's an increased risk of suicide or suicide attempts and people with chronic pain. So I just put that out there because they are very different and we shouldn't treat chronic pain as if it's just acute pain that just hasn't gone away. It really is quite different and it is quite maladaptive.
Dr Jin: So we should approach it more as treating any chronic disease, which is oftentimes very long-term or lifelong treatment.
Dr Alford: Absolutely.
Dr Jin: Okay. So in the toolkit there are 6 steps outlined as approach to good pain care, and they are, number 1, engage the team. Number 2, engage the patient. Number 3, assess the patient. Number 4, use non-pharmacologic and non-opioid therapies first. Number 5, prescribe opioids safely and have a discontinuation plan. And number 6, monitor the patient. So I do want to take a few moments to go through each step and get your thoughts on the key points. And starting off with step 1, I like how the first step says to engage the team or the word team. I like that that is in there because, of course, as with many chronic diseases and chronic illnesses, team-based approach is essential. So for chronic pain, who is that team composed of, and why is a team-based approach essential for treating it?
Dr Alford: I agree with you that I think it is critical to talk about engaging the team. So why do I say that? I say it because it's one of the most complicated things that we treat in primary care or in health care in general, because it's subjective, right? It's subjective to the patient, it's subjective to us when we're assessing it and it's time consuming. And while we do a lot of things in primary care and in health care, that's time consuming. We do it and we figure out how to do it by involving the entire team. So what do I mean? Well, it's not just the person writing the prescription. It's got to be others like medical assistants. Maybe they can do some of the screening for risk factors for misuse of the medication that we're prescribing. Nurses can help monitor patients' adherence with the treatment plan. If you're fortunate like I am, to have a pharmacist in your practice, they can also help with monitoring and education and so forth.
And certainly if you have behavioral health specialists in your practice, they can help as well in terms of non-pharmacological treatment. So it really needs to be a team effort. And I would say even outside the walls of your practice, I would include in the team community pharmacists. I mean, I think they really play an important role, right? Because they're dispensing the medications we're prescribing and they certainly can do some education around how to take the medication safely, how to store them safely and so forth, and important drug interactions and so forth. So I think partnering with everybody. And so I do find myself on the phone sometimes with our community pharmacists, with certain patients that I worry about.
Dr Jin: Yeah, because they probably have the most face-to-face contact with the patient aside from you sometimes and know the patients pretty well, I imagine.
Dr Alford: Yeah, and they're seeing them at a different point in time during the day. And some of our patients, we see them infrequently and the pharmacist is seeing them at other times. So it's good to get another set of eyes on them. And let me just say that in terms of not only engaging different individuals within your practice, but things that can help your team work better include things like patient registries, which of our patients in our practice have chronic pain, and are they being prescribed potentially dangerous medications? And are we monitoring them? And also having a list of referral resources. So if a patient has chronic pain and they need psychiatric care, do I know where to send them and can my team help me with those resources?
Dr Jin: Yes, absolutely. Can you touch on the prescription drug monitoring program, the PDMP protocol?
Dr Alford: Sure. So the good news is that all states now have prescription drug monitoring programs or PDMPs, which again, this helps, links us with the pharmacist because it's the pharmacy that inputs the data when something like a controlled substance, namely in this case an opioid, is dispensed. And so by checking the PDMP, it allows you to see if the patient is receiving prescriptions from other prescribers and if they're on dangerous polypharmacy based on what you find.
So it's a really useful tool, but I will say a lot of states in my state of Massachusetts, they've mandated that every time I write a prescription, even refills for a controlled substance that I need to check the PDMP. Now, is that evidence-based? Absolutely not. How many patients who misuse prescription opioids are doing so by going to multiple prescribers? It actually turns out to be about 1%, and that's based on some national survey data. So it's really a small proportion. It's not to say that it's not important data, but it's not the majority of patients who are misusing opioids or going from one doctor to another. But the PDMP helps you identify those individuals who you should be worried about.
Dr Jin: Got it. And then in terms of workflow, who in your practice is the one who checks the PDMP?
Dr Alford: Yeah, so again, that depends on your state. So our state and many states allow delegated authority. That is, that somebody else can look the PDMP data up on your behalf, and you need to give them permission to do so through the state PDMP program. And so our nurses look up our patients. That actually reminds me of a whole other point around engaging the team. And I mentioned earlier that we, that is physicians, have not been well-trained in pain and addiction and safer opioid prescribing, and I would argue that our team members have not either.
So let me just give you an example. So when I have a patient who has diabetes and I'm going to transition them to insulin, thank goodness I have others who can help me with that and can educate the patient on how to drop up the insulin, store the insulin, inject the insulin, check their glucometer, our nurses and pharmacists and others have been trained in diabetes management, so they are already trained and they can help me right away. You shouldn't assume though that your team members are well-versed or well-trained in pain management. And so they also need to be trained in order to help you take care of our patients.
Dr Jin: Yes, absolutely. Wonderful point. All right, so moving on to step 2, which is engaging the patient. What does that mean to you and how do you do that in your practice?
Dr Alford: So there are 2 things that I think about. One, it's important to be empathic. It's really important to be empathic for the patients' pain experience. Oftentimes they are suffering a great deal, so be empathic about their painful experience. Two, the second important point is validate that you believe their pain complaint. And I would say we should validate their pain complaint a hundred percent of the time. Why? Because there's zero percent risk in doing so. Why do I say that? Because, just because you believe the severity of their pain complaint does not mean that opioids are indicated.
And that's where our clinical acumen comes in, that is determining what is the best treatment for this patient's pain. But we have no tools to say, “OK, this person's pain is real or it's not real,” or “This patient's pain really is a 10, or really it should be a 6.” It's like, no, it's based on the patient's reported experience. And give yourself a break. Don't try to assess, is this true or not true? Just say, “Yes, I believe you a hundred percent of the time, I believe you.” The question now is, OK, based on your pain complaint, based on your risk-benefit profile, which we can talk more about, this is what I'm going to recommend for you, but don't try to figure out—is this patient's pain really a 10? If they say it's a 10, it's a 10.
Dr Jin: Ah, I like that. Tell them you believe them. Are there any other useful phrases that you use with your patients to validate their pain?
Dr Alford: When I see a patient pushing back on my suggested treatment plan, it tells me to ask them again. So why do you think I'm choosing this treatment plan? Because you'll find some patients who will say, “Because you don't really believe how severe my pain is.” And that means I need to remind them that I absolutely believe the severity of their pain. That's not the issue. The issue is, what's the best way forward? And they need to trust me that I'm going to choose the best treatment plan based on their pain and based on their risk profile.
Dr Jin: And in terms of goal setting, how do you engage the patient in that part of it?
Dr Alford: Great question, because it's important for your patient to have realistic expectations about what they can expect from your treatment plan based on their chronic pain. Now, if they're thinking, well, this is going to do away with my pain, my pain's going to be gone—that may not be realistic. And if that's what the patient's expecting and you don't clarify that, then you're never going to satisfy them with your treatment plan. So you need to set realistic goals. I like to use SMART goals because they're—let me just say what SMART stands for. They're specific, so I'm being very focused. They're measurable, so I can at the next visit say, “How did you do with this particular goal?” And there'll be some level of measurement so I can kind of see how they're doing. It's action oriented, it's realistic and it's time sensitive.
So I don't want my patients saying, “Well, I hope to just feel better now.” How am I going to figure that out over time? I'd like to hear, “Well, I'd like to be able to go shopping once a week,” or “I'd like to be able to do my laundry,” or “I'd like to go play with my grandchildren.” Well, that may be realistic, that could be time sensitive. That's very specific and measurable. And so at the next visit I could say, “Hey, how did it go? Were you able to play with your grandchildren since I last saw you? Tell me how that went.” So I think it's really important to set realistic goals and use smart goals so that you can follow up on them.
Dr Jin: Yeah. Got it. Moving on to assessment, there's 2 parts of assessment. One is assessing the pain itself. The second part of that is assessment of risk. So the risk profile, which you mentioned, which I presume is for the risk of opioid use disorder. So can you elaborate on how you do the risk profile assessment for your patients?
Dr Alford: I would be happy to, but first, let me just reflect on, why is this even an issue? We would never prescribe anti-hypertensives without measuring someone's blood pressure or treat a patient with diabetes without measuring their A1C. So why don't we do it for pain? Well, we don't do it for pain because we don't have those objective measures. It is hard to assess. It is hard to document. That's why we don't do it. It's not because we don't want to do it. It's just really hard to do it. So what do I recommend? So as we talked about, acute pain, I think it's fine to just measure the severity of someone's pain on a 10-point scale, for example, that's fine. But for chronic pain, you really want something multidimensional. You want to know, how's their pain? How's their function? How's their quality of life?
And there certainly are some very well-validated assessment tools out there, like the McGill Pain Questionnaire and others that if you can use those in your practice, that's great. But in my primary care practice, they're way too cumbersome and I can't use them. They're impractical. So what do I use? I use something called the PEG. PEG, P is for pain, E is for enjoyment of life, and G is for general activity. So you can already see that we're asking about the 3 things we care about, pain, enjoyment of life, which is quality of life, and general activity, which is function.
And the 3 questions of the PEG questionnaire are, what number best describes your pain on average in the past week? Zero, no pain. Ten, pain as bad as you can imagine. What number best describes how during the past week pain has interfered with your enjoyment of life? Zero, doesn't interfere at all. Ten, completely interferes. What about interfering with your general activity? Doesn't interfere. Completely interferes.
And I just want to say that one patient's 10 is someone else's 6 is someone else's 8. So it's hard to compare one patient to another, but at least you're asking the same questions of your individual patients over time to see if there's any movement, any change in any of these scores. So I would use the peg. I think it's a useful tool. It's 3 questions. It's been validated in primary care settings and easy to use, but you did ask about risks. Do I need to worry about potential opioid misuse in this patient? And I would say that there are specific risk factors based on observational studies that predict opioid misuse or opioid related harm, which includes misuse, overdose, and addiction. And I divide them into 2 categories.
One are medication factors and the other are patient factors. So what are the medication factors? Well certainly be on a higher opioid dose. How that is defined, it depends on who you talk to, but it's anywhere (from) 50 morphine milligram equivalents up to 90, 100, 120. Once you get over those, get to those numbers, you start to see an increase in harm or risk. Being on opioids long-term, defined as greater than 3 months. Being on an extended release, long-acting opioid puts you at higher risk for harm. The initial start, the initial 2 weeks of starting that long-acting opioid puts you at risk. And then combining opioids with other sedatives like benzodiazepines puts you at risk for harm. So those are really the medication factors. But let me talk about the patient factors. And these include having a history of mental health disorder, whether it be depression, anxiety, PTSD; having a substance use disorder history, alcohol, even tobacco, illicit prescription drug; having a family history of substance use disorder; having sleep disorder breathing like sleep apnea; and having a prior history of an opioid overdose puts you at very high risk for having a repeat overdose.
So these are the risk factors. Now, there are tools that have taken some of these risk factors and put them in a systematized tool like the ORT or the Opioid Risk Tool or the DIRE, which is the Diagnosis, Intractability Risk Efficacy or the SOAP or the STAR or the STORM. So there are all these various screening tools that have taken these risk factors and put them into a questionnaire. The problem is there's no gold standard. There isn't great evidence supporting their use. If they help you remember what the risk factors are, that's great, but I just try to remember the list that I told you, that is the medication factors and the patient factors and I document that and I move forward.
Dr Jin: Got it. So you essentially use your own clinical judgment at the end of the day.
Dr Alford: I do.
Dr Jin: OK. So moving on then to the next step, number 4, which is use non-pharmacologic and non-opioid therapies first. In a way, I feel like we as primary care clinicians have already been so bombarded by this message that no one wants to hear about it anymore, but of course it's perhaps the most important part of it all. So I do want to give you the chance to add your thoughts.
Dr Alford: Great. I would be happy to add to that because in some ways, if we think about the CDC guideline that came out in 2016 and it was updated in 2022, this is 1 of the things that they emphasize. And I would argue opioids were never the first choice. I can't imagine that someone said, “I have chronic pain,” and I would say, “Oh, let's try an opioid before trying ibuprofen or acetaminophen.” So I don't think it was ever that way. But it's worth stating. In some ways, stating the obvious that opioids are never the first choice. We should always start with non-pharmacologic treatments and non-opioids first. So let me address the kind of elephant in the room, which is, does my patient have access to these non-pharmacological treatments that have evidence supporting their efficacy? So let me take a step back even further and say, okay, first of all, my patient needs to engage in self-care.
It can't just be about me fixing their pain. They need to partner with me and they need to engage in self-care that is adhering to the treatment plan, pacing their activities if that's what they need to do and so forth. And then I think of the treatment options in 4 domains. So one are the medications. So there are opioids, but there are lots of non-opioids we use that have efficacy, especially with neuropathic pain. The medications with the best evidence for neuropathic pain include the antidepressant, tricylic antidepressants or the SNRIs, not SSRIs, but SNRIs. And so those should be first-line therapies. But then we have the NSAIDs in acetaminophen for sure.
Then there are the physical restorative treatments like physical therapy, occupational therapy, cold and heat, stretch, and some of those are available for our patients and some not so much. Certainly, the behavioral approaches like cognitive behavioral therapy and meditation and relaxation. And then the complementary and integrative therapies like yoga and acupuncture. Again, these have evidence supporting their efficacy. The problem is that they're not always available to our patients. They're not always paid for by insurance companies.
And then finally are procedures, certainly some pain responds to certain nerve blocks, steroid injections. So I think there are lots of things that we could think about with our patients. The important thing is to one, treat chronic pain as it is a kind of chronic complex problem that requires multidimensional care, right? As opposed to acute pain where you could prescribe a medication and it's going to get better on its own and the medication will probably make them feel better. Chronic pain is a lifelong problem for most patients, and a medication in and of itself is not going to do the trick, most of the time. Patients who have severe chronic pain oftentimes need, require multidimensional care with the things that I described to you.
Dr Jin: I do appreciate that you brought up the equity issue in terms of access to these modalities of treatment. And the final thing I will say is that those CDC guides that you were referencing are just specifically for treatment of chronic non-cancer pain. So outside the cancer population. Moving on now to step number 5, which is now we're at the step where we prescribe opioids and the focus is prescribing them safely and have a discontinuation plan.
Dr Alford: So I think it's the elephant in the room, right? Are opioids even effective for chronic pain? And I've heard absolutely not. They are not effective. You should not be prescribing them for chronic pain. Well, let's look at what the evidence shows. I'm here to tell you that there are meta-analysis of very high-quality studies that when comparing opioids versus placebo, that opioids had a significant but small improvement in both pain and physical functioning. OK, so there's your evidence. Now, what's important to know is that the follow-up of these studies is only about 3 to 6 months. So where the lack of evidence exists is after that. And many of our patients are on these medications for years. So there, there's a lack of evidence. We don't know. It's absence of evidence rather than evidence of absence. We just don't know what the efficacy is. We know there's harm, potential harm, but we don't know what the evidence is.
But certainly for chronic pain over up to 6 months, we have good studies showing benefit over placebo. What about opioids versus non-opioids? Well, those are lower-quality studies and they show similar benefits. So that's great. So opioids are just one tool in this toolbox. And I will say that there was a highly publicized, and appropriately so, a randomized controlled trial in 2018 that compared opioids versus non-opioids for musculoskeletal pain with the outcome being improvements in pain-related function over 12 months. This was a good long-term study. And what did they find? They found that they were similar. Opioids and non-opioids were similar. But with any RCT, you then have to look at the methods to say, does this apply to my patients sitting across from me? Is it generalizable? And I would say in some cases, no. For instance, they excluded anybody that was already on opioids.
So if you've got a patient with chronic pain and opioids, they would not have been enrolled in this study. So it's already a different patient population. And then of those that were not already on opioids that were eligible, 89% said, “No thanks. I don't want to be enrolled.” So of the 11% who were not already on opioids who agreed to be enrolled in this study where they would be randomized to an opioid versus a non-opioid, there was no difference between opioids and non-opioids. So I think it's an important study, well done study, but you have to think about, is it generalizable to the patient sitting across from me?
Dr Jin: So the discontinuation plan part of it, how important is that to have at the onset?
Dr Alford: Yeah, I think with any treatment, you need to be ready to say “This isn't working,” or “This is hurting you and we need to stop it.” And we do this all the time. We start somebody on an ACE inhibitor for their hypertension and it improves their blood pressure. Great, but their creatinine goes up or their potassium goes up, and then we have to say, “Oh boy, we need to try something different.” So we monitor people for benefit and harm and we make changes based on that assessment. But again, with pain and with harm related to opioids, everything is subjective. So it's a judgment call. It's not so objective. So that makes it hard. But let me just take a step back for one minute and say, my practice has changed since all of the over-prescribing of opioids from the time in 2011 when we were at maximal opioid centric prescribing where we're prescribing opioids for everybody.
I now am much more judicious about my opioid prescribing. One, I'm really, really reluctant to start opioids. It's by far the last resort, and I really hold it as a tool, but one that I'm reluctant to use, but I will use, I absolutely will use it if I feel like it's something that's needed. And I'm talking about chronic pain for acute pain and someone who has a femur fracture, my goodness, give them an opioid for their femur fracture. Let's be humane here. But if it's some other type of acute pain, like a dental extraction, they don't need an opioid, they could do fine with an NSAID, it turns out. Along with being reluctant to start opioids, I'm reluctant to escalate the dose. And I think we ran into problems with putting people on higher dose opioids—not because that was our intention. Absolutely not.
The problem, and I think this is something that isn't often talked about, and that is there's no ceiling effect to the analgesic properties of opioids. Everything else that we prescribe, whether it be NSAIDs or acetaminophen or the adjuvant medications like TCAs or SNRIs, there's a maximum dose. You would never give more than 800 milligrams of ibuprofen 3 times a day. It doesn't make sense and you're just going to get more side effects and there's no added benefit. Opioids, we know from end-of-life care, palliative care that there is no analgesic ceiling. The only thing that's preventing us from increasing the dose in those cases is the sedation and respiratory depression. But those things people develop tolerance to. So you're prescribing an opioid as a last resort. The person has developed tolerance to the sedation and respiratory depression effects of that opioid, and they're still in terrible pain.
Remember, this is the last resort, right? You've tried everything else for their chronic pain. Well, you'll give them a little higher dose and see how that goes. And then you develop tolerance and they're still in terrible pain until you'll increase the dose a little bit more that there's still some analgesia to obtain. There's still some analgesic benefit by increasing the dose. What we now know though is despite that incremental benefit, there's a pretty big increase in risk. So despite me knowing that there is no analgesic ceiling effect, I'm really worried about the increased risk in increasing that dose. So I'm really reluctant to do so, and I certainly will tell patients from time to time, “You're on the maximum dose based on my assessment of your pain and my assessment of your risk.” And they may say, “Oh, I used to be on a higher dose,” or “I know people on a higher dose.”
And I'll say, “But for you, you're on the maximum dose.” And I think that takes some pressure off me to say, OK, your pain is still terrible and we've tried everything else and nothing else has worked and this opioid may work at a higher dose. It's like, no, I'm going to move on. I'm going to try some of the other treatments we talked about, some of the non-opioids and non-pharmaceutical therapies to try to get synergy. So that's the other one. So, reluctant to start the opioids, reluctant to escalate the dose. And then to your point, those patients who are already on opioids, you may have inherited the patient on opioids. This may be a patient in your practice who's been on opioids. I'm going to take a very careful look at them and say, “OK, is the benefit outweighing any risk or harm?” And if it is, great, I'm moving on.
I'm going to talk about their colorectal cancer screening. If I can't convince myself that the benefit is outweighing risks and harms, then it's time to make a change. It's time to taper and tapering may not be getting to zero. It may be to get it to a lower dose. So you asked me about discontinuing, and so I'm going to tell you that there is no validated protocol for discontinuing people off opioids. So how do you do it? Well, it depends on how concerned you are. If it's lack of benefit, you can do it over months to years and just take your time. If it's risk or harm, you're going to be much more in a hurry to get them on a lower dose to decrease that level of harm. But it's really important to remember or to know or to appreciate that there have been some recent observational studies that have kind of confirmed something that we were worried about in the first place.
And that is people who are tapered off their opioids, there's an increased risk of suicide and opioid-related overdose. The problem with those observational studies is we don't really know why they were being tapered in the first place. So they may have already been high risk. They probably were. But there was a really interesting recent study by a colleague of mine, Marc Larochelle at Boston University, where he did a comparative effectiveness study of about 200 000 individuals who were on stable long-term opioids and found that tapering was associated with an increased risk of overdose and suicide, and found that those individuals who were being maintained on a stable dose with no evidence of opioid misuse on the data that they had, there was no evidence of dose escalation, early refills or anything, that those people were doing just fine.
So the message from that study was, if someone is not misusing their opioid and they're stable, don't think about decreasing their opioid as some harm-reduction strategy because actually you're going to increase the potential harm by doing so. Use the benefit-risk framework, but don't just willy-nilly say, OK, I'm going to taper you off opioids because opioids are dangerous, because based on this study, if someone is stable and not misusing their opioid and you think they're benefiting, then don't taper them because you think it's somehow going to decrease their harm.
Dr Jin: Yeah, that is a good point. We really need to be weighing potential benefits versus potential harms. And then I think we are on our final step, which is monitoring patients on long-term opioid therapy. What do you do in your practice for monitoring?
Dr Alford: Yeah, so we've talked about monitoring for benefit, and I use the PEG, pain, enjoyment of life and general activity scale. And so I use that pretty regularly and compare people over time. But in terms of monitoring for potential misuse of an opioid, I check the prescription drug monitoring program, the PDMP as we talked about. But I also do urine drug testing, and I also do sometimes pill counts. So I do urine drug testing, one, to confirm that they're taking the medication that I'm prescribing, so I expect to find the opioid that I'm prescribing in their urine. I'm also looking to make sure they're not taking something else that I'm not prescribing that I should be worried about. Urine drug testing can be complex, both in terms of what you order and how you interpret it. So my message to you is, know a person in the lab, whether it be a toxicologist or a clinical pathologist who can answer your questions about the urine drug test that you send.
Sometimes a urine drug test comes back with a false positive or false negative, and you need to do a confirmatory test. Most of us will not become expert in urine drug testing. And so it really is important to know who to call to get expert consultation and guidance on how to interpret and what the next steps are in terms of testing. If you have an unexpected urine result, and I want to say, please, don't use terms like the person's urine was clean or the person's urine was dirty. Those are not clinical terms and they're stigmatizing and we shouldn't be using them. It's really the urine had an unexpected finding or the urine was consistent with the therapy the patient is on, or it was inconsistent with the therapy the patient was on because you're expecting a certain result. And if it's not the result you're expecting, then it was unexpected and you need to do something about it.
Urine drug testing is not trying to catch somebody doing something wrong. And for instance, I've taught this a lot and I'll sometimes get questions from the audience: “Well, the patient had cocaine in their urine. They didn't tell me about it, so how can I treat them? How can I be their doctor? There's a lack of trust. They lied to me.” And then I say, “Well, your patients tell you they floss every day and they're lying to you probably too. Or your patient with diabetes may not be taking their medications as prescribed, but they tell you they are. Or maybe they're not exercising and dieting like they tell you. So those may not be truths. And you don't take them personally. You don't feel like, oh, I need to fire this patient because they lied to me. No, we basically manage them. We learn how to ask these questions in a way that we get truthful responses.”
It's the same thing with urine drug testing. Tell them you're sending the urine drug test as you agreed to do to monitor them for safety. And if there's some unexpected finding, tell them you're really concerned that they had cocaine in their urine and you're concerned about the effects of that. And you're also worried about the potential interaction between cocaine and the opioid that you're prescribing. But it's not about trying to catch people doing something wrong. It's about reassessing their risk and then addressing it because we're trying to take care of patients, and this is just 1 data point to help us do that.
Dr Jin: Do you have a standing order or protocol for the urine drug testing, for example?
Dr Alford: We do. In our practice. Our nurses will tee up the next refill because all these prescriptions are now electronic, so they'll send me the refill request electronically, and before they do that, they check when was the last urine drug test? Was it an expected finding? When was the PDMP last checked? Was there an agreement? We didn't even talk about agreements, but I think agreements are also helpful. That is, having a patient review and sign and you sign a document that talks about what the kind of realistic goals are for this treatment modality, but also what the potential risks are and what the patient's roles should be in staying safe and what my role is in keeping them safe with these potentially very harmful medications.
So they also check, was there an agreement signed? When was it last signed? And then they summarize that and it's included as part of the refill request. I'm able to look at that and say, yes, I'm going to sign off on this refill. So we're able to really partner with our nurses to do a lot of that groundwork that, frankly, I don't really have the time to do myself.
Dr Jin: Yes. Yep. That was going to be my next question, is how much time or how do you have the time to do all that in one follow-up visit? But I love how you ended on that team-based care note of, that your team helps significantly with much of this work so you can develop that relationship with the patient and focus on building trust with your patients.
Dr Alford: Yeah.
Dr Jin: All right. Well, I always end by asking if there are any other final thoughts or pearls of wisdom that you want to share with either practicing clinicians or practice leaders who are looking to optimize the team-based care approach towards good pain care.
Dr Alford: I have 3 things that I want to emphasize. One, there's no question that managing chronic pain, especially when you're using chronic or long-term opioid therapy, is a lot of work. But we can do this. Don't shy away from it. We can do this. We are smart. We do a lot of complicated things in our practices in general. We treat people with very dangerous medications, but we know how to do it safely. We know how to monitor them, and we do it. We don't just say, “Oh, I don't do this.” We just have to be careful and judicious and involve our entire team to do that.
I would say second, stay in your clinician role. Do not allow yourself to become a judge or a police officer. That's not our role. That's not what we decided to go into. So make sure you're judging the treatment, you're not judging the patient. And then lastly, when you do decide to discontinue an opioid because of lack of benefit or increase risk or harm, remember, you are not abandoning the patient, you're abandoning the opioid because either it's not working or it's hurting them or both, but there's no patient abandonment here. You're doing it based on your sound clinical judgment. Despite the subjectivity of the tools that we're using, you've decided for whatever reason, and you've documented for whatever reason, that this person would be better off opioids, and you are abandoning the opioid, not the patient.
Dr Jin: Value the patients the most. And this is a team-based approach. We really need to be engaging the team, educating the team, getting buy-in from them and getting everyone on the same page in order to bring this new dimension of chronic care management into practice. So thank you so much Dr Alford for sharing all your wisdom with us today, giving us such practical tips and very good clinical pearls to help us become better clinicians for our patients. Thank you.
Dr Alford: My pleasure. Thanks for having me.
Dr Jin: And just a reminder that listeners can access the resources discussed in today's episode in the podcast description.
Speaker: Thank you for listening to this episode from the AMA's STEPS Forward podcast series. AMA's STEPS Forward program is open access and free to all at stepsforward.org. STEPS Forward can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward podcast series. STEPSForward.org.
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