Q&A: Patients with long-term opioid use face barriers to care that PCPs may fix

Patients on long-term opioid treatment struggle to receive continuous, high-quality care, two experts wrote in a research letter published in the New England Journal of Medicine.

“Patients who have been prescribed opioids for years ... must be treated differently because exposure to long-term opioid therapy causes profound physiological and neurologic changes,” Phillip Coffin, MD, MIA, FACP, FIDSA, the director of substance use research in the Center for Public Health Research at the San Francisco Department of Public Health, and Antje M. Barreveld, MD, an assistant professor of anesthesiology at Tufts University School of Medicine, wrote. “Reflexive and one-size-fits-all approaches to tapering or discontinuing opioids prescribed for chronic pain should be avoided.”

In their research letter, Coffin and Barreveld described the difficult situation that patients with long-term opioid use often find themselves in amidst abrupt closers of pain-management clinics, hesitancy from physicians to take them on as new patients and a lack of tailored care.

These “legacy patients” are at risk for being abandoned and subjected to life-threatening misapplication of opioid stewardship efforts, according to the physicians. However, primary care physicians are in a unique position to effectively treat and connect with these patients.

Healio spoke with Coffin to learn more about how PCPs should approach treating patients with long-term opioid use.

Healio: How are PCPs best suited to treat patients with long-term opioid use?

Coffin: Primary care providers develop long-term relationships with patients. This provides an opportunity to learn about not just the medical issues affecting the patient, but also the social situation, mental health concerns and life goals and objectives. Chronic pain conditions are complex and can rarely be effectively managed without attending to all of these elements. In addition, because a primary care provider sees patients on a regular basis over a long period of time, it can be easier to observe if a patient has improved or worsened under the therapeutic plan.

Healio: How should these patients be cared for, considering the CDC’s draft of updated guidance that discourages sudden discontinuation of opioids?

Coffin: The CDC is making it clear that abrupt discontinuation of opioids is dangerous, and is strongly discouraging unilateral (eg, provider-driven) tapers in the absence of significant concerns of immediate harm to the patient. Most of us have experienced inheriting patients on long-term opioid therapy and, in many cases, we would not have started opioids for their condition. In other cases, the patient’s or former provider’s adherence to opioid stewardship measures may not have met our standards. Under the CDC’s new guidance, these are not sufficient justifications to refuse to initially continue the patient’s opioid therapy. While the patient may benefit from a taper or eventual discontinuation of opioid therapy, the most important step is to develop a trusting patient-provider relationship.

In the paper, we recommend first contacting the patient’s former provider to get a sense of their treatment plan and avoid a radical divergence in care. Often, the former provider was trying to taper opioids, so the new provider can pick up that thread. Refilling the patient’s prior regimen, at least initially, is usually the correct course of action. If a taper is indicated, the provider should take the time to get to know the patient well, hopefully building a trusting relationship, before designing a plan in coordination with the patient. It's important to give the patient agency in this plan, such as by having the patient determine which medications to taper and at what rate. In some cases, this can take years. In addition to assessing for opioid use disorder and making sure they have an X waiver to be able to prescribe buprenorphine, the provider should be sure to document their management of pain and opioids. Documentation goes a long way to avoid problems with regulators.

Healio: What do you think of the CDC’s draft guidance?

Coffin: Their new guidance is a huge relief. The misinterpretation of the 2016 guidelines led to a lot of problems with clinic systems, payers and regulators. By addressing so-called legacy patients, the new guidelines offer some reassurance to providers trying to do the right thing, and hopefully will short-circuit some of the over-simplified approaches taken to reduce opioid prescribing. I'd like to see, for example, payers or regulators recognize the trend in opioid dose, so that providers could get some credit for diligently working with a patient to reduce an opioid dose from, say, 400 to 300 morphine mg equivalents.

Healio: What challenges do patients taking opioids face in terms of seeking and receiving care?

Coffin: The biggest challenge, of course, is finding a new provider when they can no longer see the provider who had been treating them. Very few providers will prescribe opioids on a first visit, and some won't prescribe opioids at all. I understand this, as I'm also not comfortable prescribing high-dose opioids for a condition like nonspecific chronic lower back pain. I don't believe they help and, instead, they can paradoxically worsen pain control through hyperalgesia. But stopping opioids is not the same as never having started them — it is a long process that has to be done in a patient-centered manner through a trusting relationship.

There is also a terrible level of stigma. This causes extreme anxiety and occurs whether or not the patient has an opioid use disorder. In addition to patient-first language and meeting patient's where they are at, another way to help address this is to have some visits dedicated to pain management. This way, the patient doesn't have to feel like every time they see the provider, whether or not to refill or taper opioids will be on the agenda.

Healio: Can you discuss the dangers of physicians rejecting patients on long-term opioid therapy out of fear of losing their license or jeopardizing their practice?

Coffin: After tapering or discontinuing opioids, multiple studies have documented increased risks for nonprescribed opioid use, an even greater concern now that fentanyl has come to dominate so many street drug markets. In addition, studies have found higher rates of ED visits for opioid-related problems, nonfatal and fatal opioid overdose, mental health crises and suicide. Less serious, but potential harbingers, include the stress patients undergo when they have to seek multiple providers. Patients may bounce from one office or ED to the next, trying to stave off the withdrawal that is expected after long-term opioid exposure. This leads to their record being flagged in prescription drug monitoring databases as "doctor shopping." That can be the start of a serious downhill trajectory for patients.

Healio: Anything else to add?

Coffin: If you believe that opioids were overprescribed, then the problem we are facing is iatrogenic. Much like addressing a complication of surgery, we all have a duty to care for patients who have become reliant upon opioids. There aren't enough pain specialists to absorb the care of these patients and we all have to contribute.

Reference:

Coffin PO, Barreveld AM. N Engl J Med. 2022;doi:10.1056/NEJMp2115244.