The Value of Shared Decision-Making in the Management of Chronic Pain
The management of chronic pain often relies heavily on physician-directed treatment decisions, rather than shared decision-making and patient participation. In many ways, the opioid epidemic is pushing the medical community to reflect on this disparity, and specifically on what appears to be the practice of overprescribing narcotics.
The opioid epidemic is a recurring theme in public dialogue. As more voices join the conversation, sentiment has begun to carry accountability for addiction straight to the doorstep of the medical profession. Lawmakers, insurers, attorneys and grass-roots groups are looking for someone to blame, and the medical profession is bound to absorb some of the scrutiny. For physicians, it may be time to arm patients who are dealing with chronic pain with information on non-narcotic treatment options and help them understand the ramifications as they select treatment plans.
“1999 TO 2010, OPIOID PRESCRIPTIONS DISPENSED IN THE UNITED STATES QUADRUPLED.”
RECOGNIZING THE PROBLEM OF OVERPRESCRIBING
The question for medical professionals is whether prescribed opioids are factoring into the larger picture. Unfortunately, the numbers tell a not-so-rosy story. From 1999 to 2010, opioid prescriptions dispensed in the United States quadrupled.1 In 2016, research by the QuintilesIMS Institute revealed that 3.3 billion pills were left unused by patients as a result of opioid overprescribing. That number is enough to give one pill each to half of the world’s population.2 Overprescribing has far-reaching implications. Based on CDC mortality data available through June 2017, 75% of those who began abusing heroin since the year 2000 say their drug abuse began with prescription drugs.3 And the problem isn’t about to slow down. Since 2001, the costs associated with opioid addiction have totaled more than one trillion dollars. In the next three years alone, another $500 billion in costs will be incurred.4
USING PUBLIC DIALOGUE TO DRIVE CHANGE
Stakeholders of every kind are now stepping up to be heard: federal and state governments; attorneys; the medical community; insurers; pharmacies; and perhaps most importantly, consumers. Government officials, according to the President’s Commission on Combating Drug Addiction and the Opioid Crisis, are calling for policies that set a new standard to ensure informed patient consent prior to an opioid prescription for chronic pain. They are also recommending the development of a national curriculum and standard of care for opioid prescribers.5
Attorneys have already made inroads to establish a new legal precedent that increasingly holds physicians accountable when their patients overdose on opioid painkillers prescribed by them. This crackdown is evident in U.S. Drug Enforcement Administration (DEA) statistics. In a five-year period, the frequency of narcotic-related doctor penalties has increased from 88 to 479. Charges against some physicians have escalated to murder charges.6
Voices in the medical community are also beginning to point a finger at their profession as a whole, citing two contributing factors to the opioid epidemic: the aggressive marketing of opioids by pharmaceutical companies and the high volume of narcotics prescriptions7, a count that has skyrocketed from 76 million in 1991 to 207 million, as of 2013.8
Some medical facilities are voluntarily limiting the use of opioids in emergency room settings, slashing prescriptions for narcotics prescribed pills from as much as 45 days to as little as five days.9 These changes align with the warnings by the Centers for Disease Control and Prevention (CDC), which caution physicians against writing long-term opioid prescriptions.9
Even pharmacies have jumped on the bandwagon, by limiting what they say physicians are failing to control. CVS Pharmacy in particular has determined to restrict physician-prescribed opioids to a seven-day supply for certain conditions.10 Likewise, large national insurance companies, including Anthem, are changing policies in an effort to reduce opioid prescriptions for members by as much as 30% by the end of 2019.11
Public sentiment is following the movement, or perhaps more accurately, public sentiment is leading the movement. One common accusation is that it is easier for doctors to write a prescription than it is to lead patients through a discovery process to identify alternate or supplementary treatment options to address chronic pain.12Deserved or not, this criticism does hold one piece of valuable insight: patients want to understand and have the option of safer treatment alternatives.
EXPANDING CHRONIC PAIN TREATMENTS BEYOND NARCOTICS
A number of health agencies, including the CDC, are sounding the call for nonpharmacological pain treatments.13,15 The effectiveness of these alternate treatment options is well-documented, and many have already found their way into the treatment portfolios of pain management physicians. This multimodal approach to pain management delivers improvement for months and even years post-treatment, versus the short-term benefit of narcotics. Some practitioners include acupuncture, massage, osteopathic manual medicine, radiofrequency ablation and physical therapy among their treatment options.14,16 The CDC has gone so far as to lay out guidelines for healthcare providers, including doctor-patient discussions about pain treatment options that do not involve prescription drugs.13
The opioid epidemic is creating a demand for pain management solutions that will eliminate or reduce reliance on narcotics. As patients participate more in the development of their own treatment plans, they will look to physicians for recommendations on new or lesser known treatment options. One such example is cooled radiofrequency ablation (CRFA), which uses minimally invasive radiofrequency technology to target troublesome nerves.16
While patient education requires a time commitment, it is an important step in the process of shared doctor-patient decision-making, a process that may help safeguard against the over prescription of addictive narcotics in the management of chronic pain.
TAKING THE NEXT STEP
For physicians who manage patients with chronic pain, the next steps can include investigating nonpharmacological treatment options, build an expanded treatment portfolio and equip patients to share decision-making and responsibility for the treatment of their chronic pain. The opioid epidemic may not be solved in one year, and perhaps not even in one decade. Each step implemented in the interim, however, will chip away at the problem, one patient and one medical practice at a time.
1Centers for Disease Control: Morbidity and Mortality Weekly Report, Vital signs: changes in opioid prescribing in the United States, 2006–2015. Retrieved from https://www.cdc.gov/mmwr/volumes/66/wr/mm6626a4.htm?s_cid=mm6626a4_won 2018, May 8.
2Compton P, Mena G., Sethi P, & Sigman P. (2017, Sept. 26). An Analysis of the Impact of Opioid Overprescribing in America, United States for Non-Dependence. Retrieved from http://www.planagainstpain.com/resources/ on 2018, May 12.
3NIDA. (2018, January 17). Prescription opioids and heroin, Prescription opioid use is a risk factor for heroin use. Retrieved from https://www.drugabuse.gov/publications/research-reports/prescription-opioids-heroinon 2018, May 12.
4Allen, G. (2018, Feb. 13). Cost of U.S. opioid of epidemic since 2001 is $1 trillion and climbing, Health News from NPR. Retrieved from https://www.npr.org/sections/health-shots/2018/02/13/585199746/cost-of-u-s-opioid-epidemic-since-2001-is-1-trillion-and-climbing (2018, May 12).
5Bondi, P., Baker, C., Christie, C., Cooper, R. Kennedy, P., Madras, B. (2017, Nov. 1). The president’s commission on combating drug addiction and the opioid crisis, p. 12. Retrieved from https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf on 2018, May 8.
6Nedelman, M. (2017, July 31). Doctors increasing face charges for patient overdoses. Retrieved from https://www.cnn.com/2017/07/31/health/opioid-doctors-responsible-overdose/index.html on 2018, May 8.
7Cavanaugh, S. (2016, Aug. 24). Department of Health & Human Services, Center for Medicare & Medicaid Services. Letter to Kolodny, A. Physicians for Responsible Opioid Prescribing. Retrieved from https://docs.house.gov/meetings/IF/IF14/20180228/106915/HHRG-115-IF14-Wstate-KolodnyA-20180228.pdf on 2018, May 8.
8Volkow, N. (2014, May 14). Senate caucus on international narcotics control, America’s addiction to opioids: heroin and prescription drug abuse. Retrieved from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2018/americas-addiction-to-opioids-heroin-prescription-drug-abuse on 2018, May 8.
9Associated Press. (2016, March 24). Medical center considers changing opioid prescribing policy. Retrieved from https://woub.org/2016/03/24/medical-center-considers-changing-opioid-prescribing-policy/on 2018, May 12.
10Charles, S. (2017, Sept. 2017). CVS to limit opioid prescriptions to 7-day supply. Retrieved from https://www.nbcnews.com/storyline/americas-heroin-epidemic/cvs-limit-opioid-prescriptions-7-day-supply-n803486on 2018, May 8.
11DeMio, T. & O’Donnell, J. (2017, Jan. 19) Anthem to change opioid treatment policy under deal with NY regulators. Retrieved from https://www.usatoday.com/story/news/politics/2017/01/19/anthem-change-opioid-treatment-policy-under-deal-ny-regulators/96771566/ on 2018, May 8.
12Pearl, R. (2018, Jan. 23). Who’s responsible for the 42,000 opioid deaths last year? Retrieved from http://robertpearlmd.com/opioids/ on 2018, May. 8.
13Center for Disease Control. (n.d.), Prescription painkiller overdoses, A growing epidemic, especially among women. Retrieved from https://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/index.htmlon 2018, May 12.
14Nodell, B. (2018, Jan. 25). Pain task force endorses alternatives to opioids. Retrieved from https://newsroom.uw.edu/news/pain-task-force-endorses-alternatives-opioidson 2018, May 8.
15Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon, RL, Wayne PM, Zador, V. (2017, Dec. 15). The Pain Task Force of the Academic Consortium for Integrative Medicine and Health. Evidence-based Nonpharmacologic Strategies for Comprehensive Pain Care. A Consortium Pain Task Force White Paper. Retrieved from www.nonpharmpaincare.org on 2018, May 12.
16Davis T, Loudermilk E, DePalma M, Hunter C, Lindley D, Patel N, Choi D, Soloman M, Gupta A, Desai M, Buvanendran A, Kapural L. (2018 Jan). Reg Anesth Pain Med. 43(1):84-91. doi: 10.1097/AAP.0000000000000690. Prospective, multicenter, randomized, crossover clinical trial comparing the safety and of knee pain from osteoarthritis. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29095245?dopt=abstract on 2018, May 8.