I worry about pain clinics. More specifically, I worry about what happens to patients enrolled in opioid treatment programs who transfer to pain clinics.
Weirdly, now there are pain clinics that also claim to treat opioid addiction. I’m not saying that the same doctor couldn’t do a great job of treating both problems, but I worry a great deal when that doctor seems to approach these two distinct medical issues as if they were the same medical issue.
Medication-assisted treatment (MAT) of opioid addiction with methadone or buprenorphine is NOT the equivalent of treating chronic pain. When I call my MAT patients’ other doctors to coordinate their care, quite often these doctors ask me if it would violate the patient’s pain contract with my facility if they were to prescribe opioids for a few weeks. When I tell them I don’t treat pain, but addiction, they are puzzled. I elaborate, and use the opportunity to educate the doctor about opioid addiction and its treatment with methadone and buprenorphine.
To be sure, there’s overlap between the two disorders. Studies estimate that anywhere from a third to a half of opioid addicts also have chronic pain issues. And we know that the treatment of chronic pain (an arbitrary definition is more than three months) with opioids can cause the patient to develop a second medical problem, addiction.
Not all opioid addicts have pain. And not all chronic pain patients develop addiction. Many people who live with chronic pain don’t use opioids. In fact, we don’t have evidence that shows long-term opioids help people with chronic pain all that much, due to the tolerance that builds quickly to short-acting opioids and their anti-pain effect. The human body makes changes to compensate for the presence of opioids, and becomes less sensitive to those opioids. Typically, the dose has to be repeatedly increased to get the same anti-pain effect, a phenomenon known as tolerance. Many of these patients may actually have worsening of their pain, called hyperalgesia, due to the changes the body makes in how pain messages are processed.
Some patients can be treated with opioids long-term (longer than three months) and continue to benefit from them without developing any addiction to them. I don’t usually see these patients, since they are doing well in their treatment at pain clinics. Possibly for genetic reasons, they never develop addiction. By addiction, I mean the obsession with and craving for opioids, and inability to control the use of opioids. They will certainly become opioid dependent, and experience physical withdrawal if opioids are stopped suddenly, but that’s physiologic. The mental obsession, a hallmark of the disease of addiction, is not present.
To illustrate further, let’s look at the new guidelines from the fifth and latest edition of the Diagnostical and Statistical Manual of Mental Disorders, more commonly known as the DSM. In the latest version, eleven criteria are used to decide if the patient has mild, moderate, or severe substance use disorder:
1. Taking the substance in larger amounts or for longer than the you meant to
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home or school, because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational or recreational activities because of substance use
8. Using substances again and again, even when it puts the you in danger
9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
10. Needing more of the substance to get the effect you want (tolerance)
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.
Only the last two criteria are physical; the rest of the criteria have to do with psychological indicators. In order to diagnose mild substance use disorder the patient has to fulfill two or three of the eleven criteria; if four or five criteria are met, the patient has moderate substance use disorder, and if six or more are met, the patient has severe substance use disorder
Addiction interferes with the patient’s ability to control the use of prescribed opioids. All sorts of bad things can happen, up to and including opioid overdose death, when a person with opioid addiction is given a month’s worth of opioids by a pain clinic.
This is my beef with pain clinic physicians. I’ve seen several examples of them prescribing opioids for a month at a time to chronic pain patients who also have been diagnosed with opioid addiction. These doctors set patients up for failure when they prescribe a month’s worth of heavy-duty opioids like Opana or fentanyl. The patient takes too many pain pills too soon, ends up in withdrawal, and gets kicked out of the pain clinic for misusing the prescription.
Is this unexpected? Is this the patient’s fault? Did the patient bring it on herself because she didn’t follow doctor’s instructions? I say an emphatic NO! Given what we know about addiction, it’s completely predictable, even expected. I’d argue it’s a failure on the physician’s part to understand the nature of addiction.
Maybe the doctor didn’t know the patient had addiction, you may argue. Maybe – but if these patients are transferring from an opioid treatment center, they would have methadone or buprenorphine in their urine drug screen. If either of those drugs were present, wouldn’t it be prudent to ask the patient for permission to call the local opioid treatment program, to see if there are records available? Wouldn’t it be prudent to see if your new patient is STILL an active patient at the local opioid treatment program?
Sometimes opioid-addicted people must take opioids for acute pain disorders, but there are ways to minimize risk, like having a dependable non-addict hold the pill bottle, only prescribing a few days at a time, and doing pill counts. Since acute pain is a short-term problem, it doesn’t carry the same risk as month after month of opioid prescribing.
I do have specific advice for the pain clinics of the world, particularly in my part of the world:
1. Get old records. If the patient is transferring from my opioid addiction treatment program to your office-based opioid treatment program, we have essential information that can help you give the best and safest treatment. More likely, you’ll get information that will keep you from harming the patient.
For example, if you want to start the patient on buprenorphine, it would be essential to know the date of the last dose of methadone, and the amount. Otherwise, you could put your new patient into precipitated withdrawal, and unpleasant experience all around.
As another example, if you’re treating a pain patient with fentanyl, you may have second thoughts – hopefully – if we have old records describing the patient’s past near-fatal overdose from fentanyl.
2. Don’t be an asshole when I call you to get information about a patient who transferred from my program to yours, then back to mine after having a relapse back to active addiction. It’s not my fault, and certainly not the patient’s fault. You should have known that a person with opioid addiction, doing well on methadone maintenance, would decompensate when you switched her to fentanyl patches and a hundred and twenty oxycodone for breakthrough pain.
I’m not trying to rub it in your face, but I am trying to educate you, in the nicest way possible, that you made a mistake. I’m hoping if I can explain to you why the patient’s decompensation was predictable, you won’t continue making the same mistake. I’m also making sure you won’t keep prescribing opioids for this particular patient.
3. Don’t let your physician assistant prescribe buprenorphine for “pain” but then also list opioid addiction on the patient’s problem list. It’s disingenuous. We all know that under DATA 2000, physician assistants and nurse practitioners can’t prescribe buprenorphine for addiction. You say it’s for pain, so that a physician extender can see this patient, but then have to tell the patient’s insurance it IS for addiction to get them to pay for it. Besides being bad medical practice, isn’t that insurance fraud?
4. When the family member of one of your patients tells you that patient is misusing her medications, please check it out. Yes, sometimes people do call prescribers trying to interrupt a patient’s treatment for malicious reasons. We have the same problem at our opioid treatment program. However, we do all we can to check on patient safety. If the third party says your patient is injecting your prescribed medication, it’s easy to call the patient into the office to look for track marks. (You do know what those look like, right?)
Doctors at pain clinics could say I’m just mad because they sometimes “steal” our patients. While I’m not happy when patients leave our treatment program, no one can “steal” patients because no one owns patients.
The biggest part of my disgruntlement all centers on the four behaviors I’ve described above. If new pain clinics/addiction treatment programs were accepting our patients who were doing well, and were appropriate for an office-based addiction treatment program…I’d be fine with that. If it worked out for the patient, and saved them time and money with no increased risk of relapse, great. I love to see patients doing well.
But I don’t think all pain clinics give good care, and I’m disturbed when patients suffer set-backs due to mismanagement.